City of Bessemer

Application for Preliminary or Final Plat

DATE: ___________

Name of Subdivision __________________

Applicant Name ___________ Phone Number ________

Address ___________ City _______ State _______ Zip Code _______

Owner of Record ___________ Phone Number ________

Address ___________ City _______ State _______ Zip Code _______

Engineer ___________ Phone Number ________

Address ___________ City _______ State _______ Zip Code _______

Land Surveyor ___________ Phone Number ________

Address ___________ City _______ State _______ Zip Code _______

Attorney ___________ Phone Number ________

Address ___________ City _______ State _______ Zip Code _______

Subdivision located on the _______ Side of _______ feet _______ of _______

(Left, Right) (Street) (Direction) (Street)

Total Acreage _______ Number of Lots _______

Legal Description of Subdivision _______ ¼ of _______ ¼ of Section _______ Township _______ Range _______ □ Attached Legal

Parcel Identification Number: ___________ □ Attached Tax Map

Present Zoning: _______ Will the property require rezoning: _______ Proposed Zoning: _______

Attach Utility Availability Letters: □ Water □ Sewer □ Power □ Phone

Type of Bonding Required for Public Improvements: ___________

□ Attached five (5) copies of the proposed vicinity sketch map and preliminary sketch plan or final 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 _______