HomeMy WebLinkAboutOwners Auth-Cert Form - Subdivision TOWN OF ITHACA
DEPARTMENT OF PLANNING
215 N.Tioga St 14850
607.273.1747
wwwAownJthaca.nv.0
SUBDIVISION 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 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 divided; that 11we agree and guarantee
to divide the property as shown on the finally approved subdivision plat and all related application
documents;and that 1/we make any dedications indicated on the final subdivision plat.
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:
5/1/2022 Once completed, please submit this form to the Town of Ithaca Planning Department.