Southtowns Record

1865 READING ROAD (full text)

Town of Aurora Zoning Board of Appeals Apr 16, 2026 12 pages

This document was a scan. Its text was produced by character recognition and may contain errors; check the original for exact wording.

Page 1

CASE NO. DATE OF HEARING Town of Aurora Zoning Board of Appeals 575 Oakwood Avenue, East Aurora, New York 14052 Zoning Board of Appeals Application Form l. TYPE OF REQUEST 2&_AREAVARIANCE __SPECIALUSEPERMIT __ USE VARIANCE INTERPRETATION I. APPLICANT/PETITIONER Applicant’s Name Way Cane po | = yogi Address AloS ReadWMNO Boad City ~—2— St Falis 9 State NY zp \\\70 Phone “illo ~B6\- 3289 Fax MA Email widemerer. © in chursing COVA Interest in the property (ex: owner/purchaser/developer) iil. PROPERTY OWNER INFORMATION (lf different from applicant information.) Property Owner(s) Name(s) Address City State ZIP Phone Fax Email Ill. PROPERTY INFORMATION Property Address 1Bl0S Read MG. RA West Fall $ WY 14 (79 SBL#__1%4.00- 3-34 Property size in acres 1.33 Property Frontage in feet__1&s' Zoning District__ Ral a Surrounding Zoning __ Raja Current Use of Property Resi derrt a2, iV. REQUEST DETAIL (check all that apply) X_ Variance from Ordinance Section(s) #_16- 8 4c (2) ____ Special Use Permit for: ____ Use Variance for: ____ Interpretation of

Page 2

V. SIGNATURES (This application must be signed by the applicant/petitioner. If the applicant is not the owner of the property, a separate owner authorization form must be submitted — see pg. 5 ) Signature of Applicant/Petitioner Mare 8 Gemneveld Print name of Applicant/Petitioner State of New York; County of Erie On the Q day of Meare}in the year DOD ( pefore me, the above individual appeared, personally known to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she/they executed the same ng purposes therein stated. at ft: Monin Notary Public LAURIE H. MONIN Notary Public, Stateof New York Registration No. 01MO6304887 (Notary stamp) " Qualified in Erie County 2 Commission Expires June 02, 0 Office Use Only: Date received: Receipt #: Application reviewed by: ECDP ZR-1 form sent to EC: Hearing publication date: PREVIOUS APPEAL(S): A previous appeal to the Zoning Board of Appeals ( ) has ( ) has not been made with respect to this property. Previous appeals: Date: Type of Appeal: Granted Denied Date: Type of Appeal: Granted Denied

Page 3

PETITIONER’S LETTER OF INTENT Please describe in detail the proposed project, reason the variance and/or special use permit is being requested and any additional information that may be helpful to the Zoning Board of Appeals in deciding this appeal: (attach additional pages if needed) Storage buotidine vs Cina Ou Ht to She lawn Wanwey and “adxmen Sveo\-esy Tae vostairs Wilt be Used bc iche\y Te eho ma Garden Su IOUEeS Soc OS pots and wrrse eawden iremns TO BE COMPLETED ONLY WHEN A USE VARIANCE IS BEING REQUESTED: AUse Variance is requested because the applicable regulations and restrictions in the Zoning Code of the Towrrof Aurora have caused unnecessary hardship as demonstrated by the following: 1) not realize a reasonable return on my property for each and every permitted use allowed in the 2) Describe why your alleged hardship relating to the subject property is unique and does not apply 4) Is your need for a use variance a result of you own actions (is your difficulty cone Please explain: \ (Attach additional pages if needed)

Page 4

Town of Aurora Zoning Board of Appeals 575 Oakwood Avenue Application East Aurora, NY 14052 Owner Authorization .townofaurora.com representative(s) access to the property to review existing site conditions during the review process. Mare R Gemone Owner (print) s|2 pore Date | Owner (signature) STATE OF NEW YORK ) Ss COUNTY OF ERIE ) On this O na day of March , 20 BIE before me, the undersigned, a notary public in and for said state, personally appeared Mark R ben ereK , persgnally known to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subsécibed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capadity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. LaureaHe Mornin Notary Public LAURIE NM Notary Public, St otk New York - LAURIE H MONIN Registration No. ONV06304887 | ts) NB te af Naw ae sh ve York 454887 valified in Erie ount Commission Expires Jun yACLAY 20 @ in Efe Goun GOREN a Lane aa! oe . 5

Page 5

due 3)4(ze Fr-4[ 16 Murti, ZONING BOARD OF APPEALS APPLICATION FORM AND INSTRUCTIONS Please Read Carefully The Zoning Board of Appeals (ZBA) has the power to issue interpretations of the Zoning Ordinanée: and to grant area variances, use variances and use permits. Application requirements: 1. Prior to seeking a variance from the ZBA, the Applicant/Property Owner must receive a denial from the Building Department for a building permit, a decision from the Code Enforcement Officer, or a referral from the Planning Board or Town Board. 2. Completed applications must be submitted by the second Monday of the month prior to the next scheduled meeting of the ZBA. The ZBA meets the third Thursday of each month. 3. All applications must be accompanied by the proper application fee. ZBA application fee is $100.00. Checks made payable to Town of Aurora. 4. If the applicant/petitioner is not the property owner, an owner authorization form must be submitted. 5. Submit one (1) original and ten (10) copies of the following information: A ZBA application with all questions answered. 2 Petitioner’s letter of intent. 3/ Sketch, drawing, plan or brochure showing all dimensions of the structure that requires a variance and any other information as may be necessary (ex: photos of the property). { Survey prepared by a licensed surveyor, licensed architect or professional engineer showing the property involved and the location of all existing structures and proposed structures. All setback measurements must be shown on the survey. 8/ A site plan showing the proposed structure and all dimensioning including distance from property lines and roadways, driveways, wells, septic, drainage ditches and any other features relevant to the variance being requested. of Copy of property deed. 7 Short Environmental Assessment Form (SEQRA) — Part 1 completed by applicant. Incomplete applications will not be accepted for review. Attendance at the Hearing: The property owner, applicant, owner/applicant’s attorney, engineer and/or architect or a duly authorized person must attend the public hearing.

Page 6

SUPERVISOR TOWN CLERK Charles D. Snyder Martha L. Librock (716) 652-7590 (716) 652-3280 csnyder(@townofaurora.com [email protected] TOWN OF AURORA Aurora Municipal Center 575 Oakwood Avenue, East Aurora, NY 14052 www.townofaurora.gov TOWN COUNCIL MEMBERS March 5th, 2026 Luke Wochensky lwochens townofaurora.co Mark Gemerek m 1865 Reading Road Joseph M. McCann West Falls, NY 14170 [email protected] Raymond M. Wrazen Mark, [email protected] The Building Department has reviewed your request for a two-story accessory structure SUPT. OF HIGHWAYS (shed) to at 1865 Reading Road. The request has been denied because it fails to meet the David M. Gunner requirement for building height of an accessory structure in the Rural Residential (RR) (716) 652-4050 zoning district in which the accessory structure (shed) is located. [email protected] CODE ENFORCEMENT OFFICER Sections 116-8.4C(2) Elizabeth Cassidy Required: For accessory buildings/structures: One story not to exceed 15 feet. (716) 652-7591 [email protected] Requested: Two-story accessory structure Variance: One (1) additional story ASSESSOR Stephen R. Pigeon [email protected] This letter serves as notice that we have received the application and fee for the Zoning (716) 652-0011 Board of Appeals. You will receive notification from the Town Clerk with the date and DIR. OF RECREATION time of the next available hearing. If you have any questions, please contact our office at Christopher Musshafen 652-7591. (716) 652-8866 [email protected] Sincerely, TOWN ATTORNEY Brigid M. Maloney TOWN JUSTICE Richard Miga Jeffrey P. Markello James Granville Assistant Code Enforcement Officer HISTORIAN Robert L. Goller (716) 652-7944 [email protected] FAX: (716) 652-3507 This institution is an equal opportunity provider and employer.

Page 7

L“ NOTE: This.su was prepared without the benefit of an NOTE: U nauthorized, horzed alteration or addition to any survey, drawing iF , specification, plan, or Abstract of Title ond is sub ject fo any state of facts po isa iolation 6 f Section 7209 , Provision 2 of the that may be revealed by on examination of such. New York State Education Low. Nyhost t 2 Seq 39 UL 1 350.00" 18.64 38.58 # * ANG —. ran THE 62.07 4] i § - 26.83 mang a S. LINE OF PARALLEL ¢ wood OF rn READI 4€.62 1 STORY | Se NG LOT WO. INCL. HIGHWAY } NO. 1865 DECK 165,008 326 ACRES? _E. LINE OF Lor 49 WITH FRAME HOUSE 60; A = 49 ea a fe . + ROAD | A wee ee ee ae RS , BLACKTOP oRive~ 2 Oye eDIFO 63.77 gtt oped \ BL PARALLEL: WITH-THE E. LINE. OF LOT Pp ~ yal 49 THE-————! 7 Oy i] S EX, REBAR . 1651.19 70 THE S.E. COR OF LOT 49 ceemnnemmr -saned

Page 8

- Stas eerie Saar “ALIDWdVD Eee Wd SV ALINOD TIVES SINTRA Se ae oo OL Dae - sigh ari ESEVANS TAM NO a eT “ P ‘SHIDNV¢RIOSIG YOLVIN JO LOALIHOWV AHL ALON ; IVINS ‘Van SEOTLES NOLLONULSNOD LNOHONOUHL ATA NI SNOISNAWIG TTY AdA — ii OMIT OL SHSCIVEH ONY SVEN a LSND = SUH 000? SAL PR a EE ee oe —_—_———S————___ SSS A : *‘SH.LON TVUANHD *‘SH.LON LOdfOudd a < 6 |6| la 45|g|tm . : 0-1=.0/1 TTVOS } — 1.0/1 -TTVOS. oe2 ie)4 =< = 4 : NOLLVAATA Uva NOILLVAYTH ACIS LHD a I® aT i (e) a2 ae Tec ah Ta) eel pea Faget Cet 8 = Z el ITs ty 3 ee SWHld ‘NOOO ve et Talley Eth tIty re n : 11 Tr I TT i & 2 — =Ss === 7 — iP = — — = =—— == — TiVLad WANYOO 01 = U1 Laos é Z a Es * Sas Sy "1 é | : ee —= — | PS ee ee ——— SS bi H [ i] SS il= —« ——— | a al q Ve 7: Wvdd AO dOL eat hog 2 SS Last H E] ect . OLLVd = 2 ae i ——— eo es | | i = ss L le — 5 ————— 2) a s = Se eee iy ee eee ——— ——— = — T] HHI E OI ain — ya e = rat OT) ATAIST — =) — SNOO 8012 (2) — =} 2012000H NOSONS I | EEE ae —at ==} — ntsc: IW ——T HA AHL THEE YL = LHOISH NVAW = ds | 1504 “a x= fi tee aed AN td prey PAO] Peoy 149807 ¢ oy V SNV Td Wad ONIDVdS ML — NURIVIN TAU WY > NOLLVASTa AGIs aca ae 0-.1=.b/1 FTVOS NOLLVAdTd LNOY ie | ATVs 0-1 =.2/1 TIV.LAC dITO SSn TET d° Wiog [Tous @soonyaTeUNp 9€b1-L99 (91L) -Hd SNOISIAaY

Page 9

“SUIDNV.ANOSIC ANV LUOGTY CNY SOM AO DIVLS OL YORI SNOLLVOLIDadS INV SNOISNONIG TIV SOSHOL GINO AAV SHOLIVALNOD HS x (SANDW) ALVIS MHOK AMIN SEV W'L'S'V - TALS TVUNLLONULS AO HOD TVLLNRCISTY 0207 HILL dO SINGIN HLL GHOXG YO LE ‘AIL HOCETTMONY STH dO LSHE SELL OL CNV LOSLLIMOMY DNIAOY4dV BILL MSULL SAWOD wag nIA\ 'SNOLLTOATY Loos AM GELLAOCV CNV GHAIATY ATIVNOISSHAONd NIM GAVE SONIAVYC SSSI. ONTMHANIONA Ud GHSN Ad AVW YAGWNT MANDA GALVNINV1 ‘CauINOTY TAHA « ACMOTHD TANIA A10d = ‘O'A'd YOO Of HHL NO SONLIAVUCdO NOLLVOTIddv~ SONIAVUG GgANNVIS HHL NOUS SHONVED GAZINOHLAVND ANY? (VIN) WALLAG YO AGVAD Z ON “(61-CM) UL ANI iS OF. CALVAAL PANSSAAd ‘Ld HSINLI MISNVAMOA dO ALTTVAO- SNOLLDSASNI RUS WALLA YO AAVUD Z ‘ON (61-G) UT ANIA aonitas BX HONI UVNDS Ud TS YOOTA HSINET rtrd as LOO4 MAVNDS wad a's‘ YOMIALXA IV ONIAOWAAY HILL AAVUD 7 ON (61-C) MLA ANId FONAdS 10 ACO TVLLNACISAY) SANDY $Z0Z HAV ‘d) HAVUD 7 ON Gia Uli ANId HONUdS »SYaCVaH COOMATA “OMATA ONLISIXA sYGLV.LS AN 40 ga05 “IVLLNACISaY) ONIGWNId “WAI qvnda NV Yash YIVIs JO NOLLIAISAND) SNOD TV ALVId "Wd WoRLLOaTA yadSV GLVLS ONIGNY1 ANdO ado VLINAGISAW SAND a _NOMLSMULSNOD VNOLLAO ‘140 NOLLVAATA UIVIs JO NOLLSMULSNOD av ‘TaHLS JO “LSNI NVOIMEWY Ad ‘SONITTING YOd THALS TVUMLLOOULS ONINEdO —‘DNdO HOva ‘LS AN dO 8d09 IVLLNAL ICISHY) SANDY $70 HO ONIXIN 'CZTOHLAY HSIAHLLO SSTINA CV dO NOLLOAaa GNV NOLLVOMAVd NOISHG SHL YOd NOLLVOLiLdds ‘7 YALAWVIC ACISLNO ao ONIAVU AVAXUIVIS JO NOLLONULSNOD TIV ___‘NOLLVI SIONdOwA DOSSV LSI TVNOLLVN Ad ALND NO x0 NMoa SS NOLLONULSNOD GOOM YOd SNOLLVOIdIDadS NDISHG IVNOLLVN ‘1 HIVOS OL.LON SUN NOISNaWId VNINON ‘WON wALAWVIG WAGON ‘ON 7Iviaa daLNAOW ‘ai ONINAdO AUNOSVL ek‘ow LNBYELAY aa NOLLDNULSNOD LAW OL SMOANVTTAD: alts a AAI NOILOdS YIV.LS HILL “LNNOO ULV YO ONHOOUNTLY 4 ‘aHUTS ‘HLONTALS LIN OL MUNTIV BEVOIONI LLAONOO dor Yo SISAL ‘AWLL ANY LV ‘al Ca YAAdS = XHONI ONIMAHLVAA @ = AYOODALVO NOISAC OINSIaS WAWININ bokeh AHIAYDNOD ere NWN109 (1) 10EA TIGV.L SANDY 0ZOZ 29. ALONLOOS LINN AUNOSVW ALYNOD faces AVOINVHOAN = “HOA TSSVD AO BE OL GAUID: sro of “1 000'l HAOMV SNOLLVAGTA LY SALIS ONICTING - WOWIXVN = “XV porate: (()z'1O€Y ‘OLA SANOU O77 Wad] “A’S‘d 05 - IHOTI 1 svo of AYOLVAVI “AVI Bon antes 7 (aVaQ) ‘s‘d Ol - SNV Id YOO TA 02 - (AATD ‘d'S'd ‘aad ONICVvda SIOA MAN ‘STIVA LSAM 10} SNOLLVUALIV 8 SNOLLIGGV 050 a (GVA) ‘d’S'd OF - YORIGINI We poe NOLLVINSNI “INSNI SLNELY ee ORC) (HATD “d’s'd0S OLLVAO/A | ans (aVaq) ‘asd 0S - YALAWVIC ACISNI ‘al .IH oniaTina (AATD ‘d’S'd 0S - ‘LHOIH platen WIT/EL O nA 88 QL SIAWONOO TTY “IVAOYddV YOY 19a HUY OL GALLINENS CNY “suopemnoyes Aq ostaaijo payou ssojun (VAC) ‘A'S'd Ol - VINOZIIOH “ZINOH ey “ONHOOWALVM “INAINOD UV CANIVULLNG ONY ‘aW1S HLONEALS dO O€ on uotp uadvaH ee ALVNUALV ‘suoneqnoyes £q astasatpo payou ssoqun (JAI) ‘d’S‘d Ob - auvoaWnsdA9 ‘dkD “daaaieal WANIWNTY “suogutnoyes Aq astavroipo payou ssajun (VHC) ‘A’S'd O1 - GHZINIATVD ~=—“A'1VD YOO'L HSINLI AAOdY (AATD ‘A’S‘d OF - apnvo “VD Lv XHCNI NOILVIADAEE V 6 WYOA MAN AO HAOD ONITIVN LSOd dN-LTINd “LdO STUMLINUALS FSNOH YOISAVOTAOATAVL = * © UD 89 XZ (E) wIV/EL O-b=.b1'8 8 0". 1=.8/€ ‘“TTWOS FOVAVD MAN 814} NOLLOYS Neer wT SNV'Td ddd ONLLOOI ONOO «07.7 (.8¥) FLAYONOD /A THA AVM HOVE. CY ava Ft SLVa10 CNIAN NV'lId NOLLVGNNOA NV'Id YOOTH LSU : Wl GaLVdNOD Se es os 149857 SCHL RELAS NLRIVIN LAV quvod Laas ‘TI SNOUOd .» NO so1xt CALVELL Ie WAM O1/0L X9 X9 JM AVIS ‘UTA ‘ONOD uh OPO “LNOD S012 (2) MOC ee | PLOY ‘itd P2EYUO Giese LSOd dn-LTind ub/L LP wOI-LF f—————— J[SOd ‘Ld 9x9 4——___——_ Jo ISOd ‘I'd 9x9 SSS ut [6 Pe r LidAOS Ga.LNTA —~| ONICIS TANIA suood OL ¥ooTs 6 "SLE°D1D 9*Z/AN HOVUVO ddOTs Aten fo ‘O'O .91 SUALAVY 8 XZ THELS /M dVaM AN VIDSVd GOOM ~~ YAOdHT LNOD 9X7 SS 9) H) 9°O..91 LSIO£ ‘OTD 9xZ TAFE BS Mee eer “LNOO SZIXZ (Z) SLAOdS NMOd 3 Nie felon Deri SYALLOD TAALS SLSIOL OXZ 7-6 00 9 6 j 7 | “ONOD 8 ¥ 67 49dH ddd THo.Ls —~ — &eo) i TIVN GNV ANTO “LNOD SOLXZ (2) OO ..91 SUSLAVY gXxZ GOOMATd OL .t/€ |.t-6 6 OO «087 0-87 wht SNITaNa pXZ 0-82 6 TIVM AHNy 9X7 4 TIL SNOUOd .” NO ONVW Yad LNAWA yyaaNA : ‘WA’ O1/01 X9X9 ONTHIOON Tig ‘Vv 62 dIT) SSNUL ] AVIS ‘Wd ‘ONO wb 3 | ‘ONVW Yad vrudaNnn ONTIOOM A ISIN “WO 67 ac LE DTD 9X T/A | ‘O'O .91 SUALAVY 8 XZ 6 20.91 TALSSSMUTAY GOOM aaUHENIONS-Aad ] L “LNOD 501x2 (2) ‘0'0 ubhZ SNITUNd $XZ Le ae By = 0-8 ya

Page 10

Short Environmental Assessment Form Part I - Project Information Instructions for Completing Part 1 — Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding, are subject to public review, and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item, please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any item. Part 1 — Project and Sponsor Information Name of Action or Project: BLS “Karting Read Usest Falls NY 1av7d Project Location (describe, and attach # location map): Brief Description of Proposed Action: Stworage bo} ng VPetnienet Name of Applicant or Sponsor: . Telephone: / @ - We [- 3250 WM"a pl AR (206 -pole— E-Mail: Address: . SCS Koad: MY (2d O° West Fells “At | TN 170 1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, NO YES administrative rule, or regulation? If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no, continue to question 2. Fa A] 2. Does the proposed action require a permit, approval or funding from any other government Agency? NO YES If Yes, list agency(s) name and permit or approval: il H 3. a. Total acreage of the site of the proposed action? -Of acres b. Total acreage to be physically disturbed? ,Ol acres c. Total acreage (project site and any contiguous properties) owned. or controlled by the applicant or project sponsor? (-33 acres 4. Check all land uses that occur on, are adjoining or near the proposed action: [_] Urban Pel Rural (non-agriculture) [1 Industrial [-] Commercial [-] Residential (suburban) [J Forest [7] Agriculture [_] Aquatic [_] Other(Specify): [| Parkland Page | of 3 SEAF 2019

Page 11

5. Is the proposed action, N/A [IC é Ai] & a. A permitted use under the zoning regulations? b. Consistent with the adopted comprehensive plan? oO Z 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? 6) )}é) 0 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area? Z| KIKI If Yes, identify: 8. a. Will the proposed action result in a substantial increase in traffic above present levels? b. Are public transportation services available at or near the site of the proposed action? c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed action? 9. Does the proposed action meet or exceed the state energy code requirements? If the proposed action will exceed requirements, describe design features and technologies: x 10. Will the proposed action connect to an existing public/private water supply? NO | YES If No, describe method for providing potable water: m q 11. Will the proposed action connect to existing wastewater utilities? NO | YES If No, describe method for providing wastewater treatment: 12. a. Does the project site contain, or is it substantially contiguous to, a building, archaeological site, or district NO | YES which is listed on the National or State Register of Historic Places, or that has been determined by the Commissioner of the NYS Office of Parks, Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory? 13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain NO wetlands or other waterbodies regulated by a federal, state or local agency? b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? If Yes, identify the wetland or waterbody and extent of alterations in square feet or acres: Page 2 of 3

Page 12

14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: [_]Shoreline x Forest Pt Acricultural/grasslands [_] Early mid-successional Clwetland (1) Urban [Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or NO Federal government as threatened or endangered? [8 16. Is the project site located in the 100-year flood plan? ES re KsKla 17. Will the proposed action create storm water discharge, either from point or non-point sources? RI If Yes, ee a. Will storm water discharges flow to adjacent properties? b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water or other liquids (e.g., retention pond, waste lagoon, dam)? If Yes, explain the purpose and size of the impoundment: Kl 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste NO | YES management facility? If Yes, describe: = 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or NO | YES completed) for hazardous waste? xX L_ If Yes, describe: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: Lu AV, fe RX Cale Le. Date: 3/ >/ 2D & Signature: L+ FA —— te Title Ot + PRINT FORM Page 3 of 3

Back to the document