Authorization Agent Form Michael Borgos, Esq. JMa Variar=[2til4approvad; Se+ptcmbor212016]
This page include the I.)Authorization to Ave as Agent Form, 2.) Engineering Fee Disclosure;3.)Authorization for Site Visits; 4.)
Ctlter Permit Responsibilities;5.)Oifficial Meeting Disclosure and G.)Agreement to provide dacumentation required,
Ow 's AGENT FoRm- Complete the following if the OWNER of the property is not the sauce as the applicant:
owrw,
Designates: as Agent regarding the following:
Variance Site Plant Subdivision
For Tax Map No,,. Deed Refeaenw: Book_... Page Date
OVOgE)R SIGNATT,TRE; DATE:
ArpmcANT's AGENT lFoRn Complete the fallowing If the APPLICANT is unable to attend the
mooting or wishes to be raprestntM by another party:
Owner:
Designates: as Agent regarding the following:
Variance Sita Plan Subc�ivisian_
For Tax Map No., P-chrome: Book�� Page�l�abe
OWNER IGNATIIE• � '{
DACE: *//-��Z"'
ZJ ENGINEEil I G FEE DISCLOSURE: Apflivationii may be referred to the Town consulting eagineer for revisor of septic
design, storm drainage, etc. as determined by the Zoning or Planning Department, Fees for engineering review services will be
charged directly to the applivant. Fees Rw engirrwriag review will not exceed S 1,000 without notification to the appbcant,
3.1 AUTHORIZATION FOR SITE VISffS: By signing this PaSP and submitting the application materials attached herein, the
Owner,Applicata, and his%uftheir agent(s)hereby authorize the Zoning Board or Plamriing Board and Town Staff to enter the subject
properties for the purpose of reviewing the application submitted.
4.I OTHER PERMIT RESPUNS1 B1 TIES:, Other permits may be regWrcd for construction or alteration activity subsequent to
approval by the,Zoning Board or pluming Board, It is the applivanVs responsibility to obtain any additional pernnits.
S.} OFIFICLA- • PdEETING MINUTES DISCLOSURI: It iA the practice of the Community Development Department to have a
designated stenographer tape record the proceedings of meetings resulting from application,and minutes transcribed from those tapes
constitutes tido official record Fall pmceodiw.
6.t AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED- I, the undersigned,have thoroughly read and understand
the instructions for subruission and agree to tine submission requirements, I acknowledge no construction activities shall be
commenced prior to issuance of a valid p&T ft. I certify that the application, plans and supportlug matarials are a true acid complete
statemmtldescriptica of the existing conditions and the work proposed, and that all work will be perf meed in aacordanca with the
approved plans and in conformance with local zoning Mulatiom. I ackuov lodge Haat prior to occupying the facilities proposed, I or
my agents, will obtain a certificate of occupanvy as accessary, I also understand that Vwe may be required to provide an as-built
survey by a Iio=sed land wrveyw of all newly constructed facilities prior to issuance of a ceitkifaoate of occupancy
I have ad and Ae e.
i * -rwt Name.[Applicant Dobe
endears Agent) PrintName [Agent) ' signed
PW?