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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.