Text · page 11 of 31
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: . public private (well) n/a Is this existing QIN Proposed sanitary sewer: public private (septic) _—s n/a __siIs this existing GUN Hours of operation (if applicable): Day Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday | By Appt. Hours | sn 2pm Waa: Lem |lOxn- Zen | fogn-Zpm| /dnt-lpe|(am- Zpm wa | Peak hours: AJA Number of employees (if applicable): Full-time Part-time va seasonal Upon approval of this application, the applicant intends to apply for: (Check all that apply) a. Building Permit 7 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 Koplicant/Pe Hioner | State of New York; County of Erie On the 3dbday ofa in the year A024 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 purpoges therein stated. MICHAELD. SAMULSKI (Notary stamp) NOTARY PUBLIC, STATE OF NEW: Fa COUNTY LIG.'# O1SAB392845 COMM’ EXP. ae ai mth eee rR SO meh Se) PL Sa Hem weet et mr fae MON A DY NEN MOT WO BNET ATT SA SAN ND Nem He A FN Wk me ‘ane nate Se nn Sel ee OE CO Som Ma RU Hy ks Fah OY SED AEE SO AD Ph HE SE SY SN SE SRG Sh SHRM OY UN RE HA eS li TSP SS A ed HB Sony) Pd NL Od Office Use Only: Date received: Receipt #: Application reviewed by: