APPLICATION FOR PARCEL SPLIT

Owner _______________________________________________ Telephone ______________________

Address _____________________________________________________________________________

Attorney _____________________________________________ Telephone ______________________

With ________________________________________________________________________________

Address _____________________________________________________________________________

Subject property located at number ________ on the  N   S  E  W  side of ________________________

between __________________________________ and ________________________________.

Required attachments:

- Legal description of the original parcel (if lot of record, describe here)

__________________________________________________________________________________

- Deed with legal description of parcel created.

- Drawing of the parcels including all pertinent dimensions.

I hereby declare that I am duly authorized to submit this application and that all above and attached information is correct.

Signature __________________________________________ Date ___________________________

With ______________________________________________________________________________

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Split Approved / Denied

__________________________________________________    _________________________
   Director of Public Service                                                         Date