I furthermore certify that the following persons are owners of properties adjoining this property. A copy
of an applicable map must be attached which labels each of the adjacent property owners with the
corresponding numbers listed below and/or GEO Pin Numbers.
Attach extra sheets if necessary.
Owner’s Statements & Signatures
[Required if applicant is not property owner]: In filing this application for a variance I/we, as the property
owner(s), hereby certify that all of the information presented in this application is accurate to the best of my
knowledge and belief. I hereby authorize the applicant to submit an application affecting the use of my property.
Signature of Owner(s): Date:
[Required if owner wishes to establish an agent (attorney, real estate agent, etc.)]: I/we hereby designate
_________________________________________ to act on my behalf regarding this application, to receive and
respond to administrative comments, to resubmit plans on my behalf, and to speak for me in any public meeting
regarding this application.
Signature of Owner(s): Date:
Applicant Signature: ____________________________________________________
Address: ____________________________________________ Phone: _________________________
Date: _______________________________________________
