FORM 3 . APPLICATION FOR FINAL PLAT APPROVAL

D                                                                      

1.   Name of Subdivision                                                                                              

2.   Name of Applicant                                                    Phone                                    

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

3.   Name of Local Agent                                                                                             

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

4.   Owner of Record                                                      Phone                                     

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

5.   Engineer                                                                 Phone                                      

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

6.   Land Surveyor                                                         Phone                                     

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

7.   Attorney                                                                                                               

   Address                                                                                                                 

       (St. No. & Name)         (State)         (Zip Code)

8.   Subdivision Location: On the                         side of                                                

                           (Street)

                  feet                          of                                                                           

         (Direction)

9.   Zoning                                                                                                                  

10.   Total Acreage                                     Number of Lots                                             

11.   Tax Map Designation:    Section                       Lots(s)                                       

12.   Has the Board of Zoning Appeals (Zoning Board of Adjustments) granted any variance, exception, or special permit concerning this property?                                                                                         

If so, list Case No. and Name                                                                                    

13.   Date of preliminary plat approval                                                             

14.   There shall be an offer of irrevocable dedication as per the specifications of the City Attorney.

15.   Have any changes been made since this plat was last before the Commission?               

   List of all contiguous holdings in the same ownership:

   Section                                                    Lot(s)                                                      

Attached hereto is an affidavit of ownership indicating the dates the respective holdings of land were acquired, together with the book and page of each conveyance into the present owner as recorded in the County Recorder of Deeds (County Clerk) Office. This affidavit shall indicate the legal owner of the property, and contract owner of the property, and the date the Contract of Sale was executed. IN THE EVENT OF CORPORATE OWNERSHIP: A list of all directors, officers, and stockholders of each corporation owning more than five percent (5%) of any class of stock must be attached.

The applicant hereby consents to the provisions of 2.1% (2) of the subdivision regulations providing that the decision of the Planning Commission shall be made within thirty (30) days after the close of the public hearing on final plat approval:

STATE OF                                                                      

COUNTY OF                                                                   SS.:

I,                                                                            , hereby depose and say that all the above statements and statements contained in the papers submitted herewith are true.

                  Mailing Address                                                  

                         (Street)

                  (City)         (State)         (Zip)

Subscribed and sworn to before me this           day of        , 20     .

                  Notary Public

MY COMMISSION EXPIRES: