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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)
Print name of ApplicanUPetitioner
State of New York; County of Erie
On the/~ day ofjf-/1'7 C" in the yearZO:z.t;,, 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 therein stated.
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(Notary stamp) i 1::.: Qualified in : °' i
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Office Use Only: Date received: Receipt#:
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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:
- - - - - - - - Type of Appeal: _ _ _ _ _ _ _ _ _ __
Date: Granted Denied
Date: - - - - - - - - Type of Appeal :_ _ _ _ _ _ _ _ _ __ Granted Denied
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