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Proposed water service: _ XX public private (well) n/a Is this existing QIN Proposed sanitary sewer: public private (septic) n/a Is this existing QIN Hours of operation (if applicable): Day Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday | By Appt. HOUrs | Osm-Zpem Waar Lp Orn - Zon [oan bpm [bat lpm lOam- Lom \/ | a | U f ‘ ™~ Peak hours: A /A Number of employees (if applicable): Full-time Part-time wa 2 Seasonal Upon approval of this application, the applicant intends to apply for: (Check all that apply) a. Building Permit b. Sign Permit y IV. SIGNATURE (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. 4) Print name of* Ropiicant/Pellliones " State of New York; County of Erie On the3dbday of daly in the year2O2S 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 purposes tneres stated. Mschod) ty, ¢fonult). Notary Publie~ MICHAELD. SAMULSKI (Notary stamp) NOTARY PUBLIG, STATE OF NEIZW YORK ERIE COUNTY “* LIC..# 01SA6392645 COMM: EXP. 06/03/209; ee ee ne ee ee ec ee a ey co ete te Office Use Only: Date received: Receipt #: Application reviewed by: