HomeMy WebLinkAboutOwners Auth-Cert Form - Subdivision fillable
DEPARTMENT OF PLANNING
215 N. Tioga St 14850
607.273.1747
www.town.ithaca.ny.us
SUBDIVISION REVIEW
OWNER’S AUTHORIZATION & CERTIFICATION FORM
I/We 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, I/we 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.
I/we also certify that I/we have caused the land to be surveyed and divided; that I/we agree and guarantee
to divide the property as shown on the finally approved subdivision plat and all related application
documents; and that I/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:
Once completed, please submit this form to the Town of Ithaca Planning Department.
5/1/2022