HomeMy WebLinkAboutOwners Auth-Cert Form - Site Plan TOWN OF ITHACA►
N E W Y 0 R K
DEPARTMENT OF PLANNING
215 N.Tioga St 14850
607.273.1747
wwwAownJthaca.nv.0
SITE PLAN REVIEW
OWNER'S AUTHORIZATION & CERTIFICATION FORM
IMe hereby affirm that I/we am/are the owner(s) of the property located at:
Property Address/Location(s):
City: State: Zip Code:
Tax Map and Parcel Number(s):
By signing below, 11we authorize the individual(s) identified in the following section to act as my/our
authorized agent regarding any and all site plan application(s) made to the Town of Ithaca Planning Board
for the activities described. The individual(s) identified below shall remain in this capacity regarding any
applications and subsequently issued permits related to these activities indefinitely unless an express
written request to terminate this authorization, signed by me, is submitted to the Town of Ithaca Planning
Department.
11we also certify that 11we have caused the land to be surveyed and the site plan to be prepared; that 11we
agree and guarantee to construct the project and any required infrastructure elements in the manner
presented by the finally approved site plan; and that 11we make any dedications indicated on the final site
plan.
Project/Activity for which Application is being made:
Signature of Owner(s): —Date:
Signature of Owner(s): —Date:
Printed Owner(s) Name:
Printed Owner(s) Name:
Printed Name of Applicant/
Owner's Authorized Agent:
Address:
City: State: Zip Code:
Telephone Number:
Email Address:
Signature of Applicant/Agent: Date:
Once completed, please submit this form to the Town of Ithaca Planning Department.
5/1/2022