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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 [Seaieam (esue— Print name of Applicant/Petition’ér State of New York; County of Erie On the [d day of Aone Nin the year 2° 2© before 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 for the purposgs” herein stated. 1 fary Publi¢ Notary stam ( ry THERESA L. GARVEY p) Notary Public, State of New York Qualified in Erie Co unty My Commission Expires FGa [oy ZL 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