2462_001 · OPW19/0168

 l, (l1¿lsca Dft¿GtE
                                                                                           Insert full name.l



 as owner of the premises identified as follows



            llnsert sfreef address, lot on plan description or coordinates of the premises the subject of the
                                                                   ¿ts6-}                       application'l
      slg ¡{ltm ,s'rca€Tt Lt              e cove @to


consent to the making of a development application under lhe Planning Act 2016 by:

  Lto¡'t t^tot-F D6slêñ-S                                                         llnsert name of applicant.l



on the premises described above for:


        llnsert details of the proposed development, e.g. material change of use for four storey apartment
                                                                                                  building.l
  UPG¿êæ, ÐAvew*_¡ CeogÍ ovet_




                                                                                     lsignature of owner and
                                                                                       .          date signedl




                                                                                            Applicant template I 0.0
                                                                                           Version 1.0-3 July 2O17