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Page 1 of 5 SAMPLE STATEMENTS FOR PARCEL & FINAL MAPS Owner’s Statement (I / We) hereby state that (I am / we are) the owner(s) of or have some right, title or interest in and to the real property included within the subdivision shown on the map; that (I am / we are) the only person(s) whose consent is necessary to pass clear title to said real property; that (I / we) hereby consent to the making and recording of said map and subdivision as shown within the distinctive border line. (I / We) hereby offer for dedication in fee simple to public use all streets and portions of streets not previously existing as shown on the map within said subdivision and also dedicate to public use easements for any and all public uses under, upon and over said streets and said portions thereof. [NOTE: This statement shall be accompanied by a Certificate of Dedication statement, pursuant to Subdivision Map Act Section 66477.5. See sample Certificate of Dedication statement below.] (Public Service Easement) (I / We) also hereby dedicate to public use easements, together with the rights of ingress and egress, for any and all public service facilities including poles, wires, conduits, storm sewers, sanitary sewers, gas, water and all public utilities and any and all appurtenances to the above, under, upon, or over those certain portions of land delineated and designated as (Public Service Easement). Said public service easements are to be kept open and free from buildings and structures of any kind except public service structures, irrigation systems and appurtenances thereto, lawful fences and all lawful unsupported roof overhangs. (Public Storm Drainage Easement) (I / We) also hereby dedicate to public use easements for storm drainage purposes under, on, or over those certain strips of land designated and delineated as (Storm Drainage Easement) said easements to be kept open and free from all buildings and structures of any kind except irrigation systems and appurtenances thereto, lawful fences and all lawful unsupported roof overhangs. (Sidewalk Easement) (I / We) also hereby dedicate to public use easements for sidewalk purposes and appurtenances thereto and the right to construct, install, use, repair, replace and maintain a public sidewalk on or over those certain strips of land designated and delineated as (Sidewalk Easement). ---PAGE BREAK--- SAMPLE STATEMENTS FOR PARCEL & FINAL MAPS Rev. 2/15/2023 Page 2 of 5 (Emergency Vehicle Access/Ingress Egress Easement) (I/We) also hereby dedicate for public purposes easements of ingress, egress for emergency vehicle access, under, on or over those certain strips of land delineated and designated as E.V.A.E. (Emergency Vehicle Access Easement). Said easement is to be kept open and free of buildings and structures of any kind except traffic rated underground utility company structures. (Private Drives) (I / We) also hereby reserve easements for ingress, egress and parking purposes under, on or over those certain strips of land delineated and designated as (Ingress/Egress Easements) subject to the limitations and restrictions contained in the declaration of covenants, conditions and restrictions. The private drive(s) contained within this (tract map / parcel map) are not offered nor accepted for dedication for public street purposes. (Private Storm Drainage Easement) (I/We) also hereby reserve easements for storm drainage purposes, designated and delineated as “P.S.D.E.” (Private Storm Drainage Easement) for the installation and maintenance of private storm drainage facilities. These easements are to be kept open and free from buildings and structures of any kind, except irrigation systems and appurtenances thereto, lawful fences and all lawful unsupported roof overhangs. The maintenance, repair, and/or replacement of private storm drainage facilities shall be the sole responsibility of the lot owners benefited, as determined by the appropriate covenants, conditions, and restrictions. (Private Sanitary Sewer Easement) (I/We) also hereby reserve easements for sanitary sewer purposes designated and delineated as “P.S.S.E.” (Private Sanitary Sewer Easement) for the installation and maintenance of private sanitary sewer facilities. These easements are to be kept open and free from all buildings and structures of any kind, except irrigation systems and appurtenances thereto, lawful fences, and all lawful unsupported roof overhangs. The maintenance, repair, and /or replacement of private sanitary sewer facilities shall be the sole responsibility of the lot owners benefited, as determined by the appropriate covenants, conditions, and restrictions. (On Maps that have both Private Storm Drainage Easements and Private Sanitary Sewer Easements) (I/We) also hereby reserve easements for storm drainage purposes and sanitary sewer purposes designated and delineated as “P.S.D.E.” (Private Storm Drainage Easement) and “P.S.S.E.” (Private Sanitary Sewer Easement) for the installation and maintenance of private storm and private sanitary sewer facilities. These easements are to be kept open and free from all buildings and structures of any kind, except irrigation systems and appurtenances thereto, lawful fences and all lawful unsupported roof overhangs. The maintenance, repair and/or replacement of private storm drainage and private sanitary sewer facilities shall be the sole responsibility of the property owners benefited, as determined by the appropriate covenants, conditions, and restrictions. ---PAGE BREAK--- SAMPLE STATEMENTS FOR PARCEL & FINAL MAPS Rev. 2/15/2023 Page 3 of 5 (PD)(1 Lot Condominium) (I /We) hereby state that (I am / we are) the owners of, or have some right, title or interest in and to the real property included within the subdivision shown within the distinctive border line on this map; that (I am/ we are) the only person(s) whose consent is necessary to pass a clear title to said real property; and I / we) hereby consent to the making of said map and subdivision. (I / We) hereby dedicate to public use easements for all public service facilities including poles, wires, conduits, gas, water and heat mains and all public utilities and all appurtenances, under, upon, or over those certain areas of land designated as "PSE" (Public Service Easement). Areas designated "PSE" are to be kept clear of buildings and structures of any kind except utility company structures, lawful fences, and lawful roof overhangs. Areas designated "PSE" may be paved, planted, or improved by the construction of private roads, sidewalks, patio slabs, or fences. Such areas shall be kept clear of buildings of any kind excepting those buildings subsequently designated upon a recorded condominium plan. Certificate of Dedication in Fee The City of Campbell shall reconvey the street dedication to the below-named owner or successor in interest if the City determines pursuant to Government Code Section 66477.5 that the same public purpose for which the property was dedicated does not exist or the property or any portion thereof is not needed for public utilities. [Owner Name as it appears on the Title Report] [Owner Address] City Engineer’s Statement I hereby state that I have examined the within (Parcel/Tract) map; that the Map is substantially the same as it appeared on the tentative map, and any approved alterations thereof; and that all provisions of the California Subdivision Map Act and any local ordinance applicable at the time of approval of the tentative map, if required, have been complied with. Amy Olay, RCE 61922 Date City Engineer, City of Campbell City Surveyor’s Statement I am satisfied that the within (Parcel/Tract) Map is technically correct. Anne-Sophie Truong, L.S. 8998 Date Acting City Surveyor for the City of Campbell (CSG Consultants, Inc.) ---PAGE BREAK--- SAMPLE STATEMENTS FOR PARCEL & FINAL MAPS Rev. 2/15/2023 Page 4 of 5 City Clerk’s Statement (with ROW and easement dedication on map) I hereby state that this map, designated as (a Parcel Map/Tract 1234), consisting of (number of sheets) sheet(s), was approved by the City Council of the City of Campbell at a regular meeting of said Council held on the day of and that said Council accepted, subject to improvement, on behalf of the public, the dedication of all streets and easements offered for dedication, as shown on said Map within said subdivision, in conformity with the terms of the offer of dedication. Clerk of the City of Campbell By: Andrea Sanders Date City Clerk’s Statement (with ROW and easement dedication and vacation of Public ROW as part of map) I hereby state that this map, designated as (a Parcel Map/Tract 1234), consisting of (number of sheets) sheet(s), was approved by the City Council of the City of Campbell at a meeting of said Council held on the day of and that said Council accepted, subject to improvement, on behalf of the public, the dedication of all streets and easements offered for dedication, as shown on said Map within said subdivision, in conformity with the terms of the offer of dedication; and that pursuant to section 66434(g) [or 66445(j) for Parcel Maps] of the Subdivision Map Act all of the XXXX square feet labeled “Street Vacation” as shown on Sheet XX herein and previously dedicated to the City of Campbell per (Book XXX of maps at pages YY and ZZ)(Book XXX Official Records page YY), Santa Clara County Records, is hereby vacated. Clerk of the City of Campbell By: Andrea Sanders Date Basis of Bearings (Sample) The bearing N 89°5'33" W of the centerline of Campbell Drive as shown on that certain map of Tract No. 1234 recorded in Book 235 of Maps at Page 75, Santa Clara County Records, and as found monuments, was taken as basis of bearings for this map. Soil Report A soils report was prepared by dated 20__, and signed by and is on file at the office of the city engineer. ---PAGE BREAK--- SAMPLE STATEMENTS FOR PARCEL & FINAL MAPS Rev. 2/15/2023 Page 5 of 5 Surveyor’s Statement This map was prepared by me or under my direction and is based upon a field survey made in conformance with the requirements of the subdivision map act and local ordinance at the request of on 20__. I hereby state that the survey is true and complete as shown; that all the monuments are of the character and occupy the positions indicated, or that they will be set in those positions on or before 20__; and that monuments are, or will be, sufficient to enable the survey to be retraced, and that this (final/parcel) map substantially conforms to the approved or conditionally approved tentative map, if any. Date 20__ Acknowledgment (For Use On Maps) A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California )SS. County of Santa Clara On before a Notary Public in and for said State, personally appeared who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand Signature Name (Print) Principal County of Business My Commission Number My Commission Expires