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Proposed water seiiee: OS _ publieetna private (well) t/a Is this existing Gis
Proposed sanitary sewer: vata, PUBIC a private (septic). n/a is this existing (IN
Hours of operation tt applicable):
Day ___| Monday "| Tuesday "| Wednesday |Thureday [Friday | Saturday | Sunday | By Appt.
Hours |4a eee ss ae NO Us zs sD ce
Paak hours: oar) oy .
Number of employees (if applicable): Fulltime 2 Parttime | ae Seasonal —
Upon approval of this application, the ‘applicant intends to apply for: (Chack all that apply}
a. Building Permit “i
b. Sigh Permit
N.. SIGNATURE (This application must be signed by the applicant/oetitioner. if the applicant is not
ihe owtier of the property,a separate-owner authorization form must be submittad — see pg. 4}
Connuph oD
Signature of Applicant/Petitioner
ae
Ca se Cordes
Print name of Applicant/Petitioner
State of New York; County of Erle
on theGnd tay ot Ma een the year 20 20%sefors me, the
above individual appeared, personally known to me on the
basis of satisfactory evidence to be the Individual whose
name is. subscribed fo the within instrument and
acknowledged to me that he/she/they executed the same
ae
fot stat et en ~ a AVET vie a
eH THC,
a 'g .* +s 4,
Nota Pane ihn PUBLIC
‘ore
‘ Qualified in
Erle Count ty
{Notary stamp}
Office Use Only:
Application reviewed by: