By signing this statement in the presence of a notary public, I attest to the fact that the cabin to be constructed at the site listed above:

1. Will be utilized for recreational activities only.
2. Will not be utilized as a domicile or residence by myself or any other person for any period of time.
3. Will not be used for any commercial purposes.
4. Will not exceed two stories in height (excluding the basement, if any).
5. Will not be used as a place of employment.
6. Will not be a mailing address for bills or correspondence.
7. Will not be listed as any individual’s place of residence on a tax return, driver’s license, vehicle registration or voter registration.

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Owner Signature 


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Date


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Notary Name


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Date Commission Expires