Plat Name: ___________________________________________________ Plat Date: _______________
Subdivider Name: ______________________________________________ Phone #: _______________
Email: _______________________________________________________________________________
Subdivider Name #2: ____________________________________________ Phone #: _______________
Email: _______________________________________________________________________________
Surveyor Name & Firm: _________________________________________________________________
License Number: _______________________________________________ Phone #: _______________
Email: _______________________________________________________________________________
___ Prepared by Virginia certified professional engineer or land surveyor
___ Location of existing and proposed monuments
___ Location of existing structures and drain fields and reserve areas shown
___ Location of any grave, object or structure marking a place of burial shown
Plat Features:
___ Note and title bar identify asBoundary Line Relocation” or “Boundary Line Vacation”
___ Note identifying name and address of legal owners. If owner is a corporation, then provide
name and address of chief office of the corporation
___ Note identifying tax parcel map numbers and parcel ID numbers
___ Note identifying zoning district
___ Reference Special Use Permit, Proffered Conditions or Variance (if applicable)
___ Reference Agricultural and Forestal District Information (if applicable)-Section 8-174(11)
___ Reference Conservation Easement Information (if applicable) Section 8-174(12)
___ Reference Dam Inundation Zone (notation shall be placed on plats, if applicable)-Section 8-174(13)
___ Location of all known drainage easements, utility easements, sewer lines, water lines, gas lines,
power lines, manholes, or fire hydrants-Section 8-174(14)
___ North arrow with source of meridian shown
___ Date of drawing and graphic scale shown
___ Vicinity map shown at a scale of no less than 1 inch equals 2,000 feet 8-174(17)
Note referencing Board of Supervisors resolution date (if ROW or easements to be vacated by this
Lot design and arrangement:
___ Location and dimensions of existing and new lot lines shown for all lots- Section 8-171(c)
Location of vacated lot lines shown ___
___ Acreage of old and new lots shown
Lot assignment table shown (if A-1 or C-1 districts) and completed correctly ___
Meet minimum lot size for zoning district ___
Meet minimum lot frontage on a public street for zoning district ___
Meet maximum length/width ratio for zoning district (if lot less than 20 acres) ___
Meet minimum setbacks for any existing structures ___
Verify total number of lots not increased ___
Street names, route numbers and right-of-way width shown ___
Public Utility and Drainage Easements:
___ Location of all existing, new or vacated public utility easements shown
___ Location of all existing, new or vacated drainage easements shown
lat Statements:
Owner’s Statement to be signed by all owners ___
___ Include dedication to Montgomery County (if new public right-of-way or easements)
Notary’s Statement for signatures of both owner’s ___
Conforming statement signed by surveyor/engineer ___
Source of Title signed by surveyor/engineer ___
Seal of surveyor signed by surveyor/engineer ___
___ Approving Statement to be signed by Subdivision Agent
ec 2020 BLA Checklist | PAGE 2
This sheet is intended to only be a
guide for subdivision regulations.
Please see the Montgomery County
Code for the specific regulations. The
full texts of the zoning and subdivision
ordinances are available at the
Planning Department Webpage or at