City of Bessemer

Application for Resurvey Plat

Date ___________

Name of Subdivision ___________

Name of Applicant ___________

Owner of Record ___________

Surveyor ___________

Property Address ___________

Parcel Identification Number ___________

Previous Subdivision Name ___________

__________________

Lot Numbers (Attach Plat Map of Original Subdivision)

Existing Parcel Zoning ___________

Name of Applicant ___________

Will The Property Require Rezoning? □ YES □ NO

Proposed Zoning ___________

Will Public Improvements be Required by Resurvey? □ YES □ NO

□ Attach five (5) copies of resurvey plat.

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

Signature ___________ Title ___________

Address ___________ City _______ State _______ Zip Code _______