Text · page 3 of 64
This document was a scan. Its text was produced by character recognition and may contain errors; check the original for exact wording.
Proposed water service: S public private (well) nva Is this axisting WIN
Proposed sanitary sewer: _ public XS private (septic), n/a Is this existing YUN
sy [Su ae
“Monday” Tuesday, "| Wednesday 7 Thursday eee “By Ap
SA:
Os aoe a ek as (ial
Peak hours: f your |
Number of employees (if applicable): Fulltime seven Le Seasonal
Upon approval of this application, the applicant Intends to apply for: (Check all that apply)
a. Building Permit
b. Sign Permit
{V. SIGNATURE (This application must be signed by the appllcant/petitioner. if the applicant is not
the owner of the property, a separate owner authorization form must be submitted - see pg. 4)
Conpupl Lonug a DA -
Signature of Applicant/Petitioner
(assy Clove ~
Cas ey Co areve
Print name of Abplicant/Patitioner
State of New York; Courity of Erie
On theFnbiay of Lett the year 22°2Chefore ma, the
above individual appeared, personally Known to me on the
basis of satisfactory evidence to be the individual whose
name fs subseribed to the within instrument and
acknowladged fo ne that he/she/they executed the same
ema LLL
ford er pufpores therein ¢stead ee RS KEL Ber,
Nose? Publ
— SP
5 “FoRNW
aH SP,
YORE
Re,
tary Public f Pygean PUBLIC %
& ae =
Bi Qosiiiod in igs
& xl Ere unl, igs
(Notary stamp) oo Resa ee
Offiee Use Only: Date recelved: 3 | ly [Ze Reeslpt & Wike) oS,
Application raviewed by: