AUTHORIZATION PAGE Sign Wrial]CC 17HAapproved Noytimber IS,2019)
This page includes the 1.)Authorization to Act as Agent rorriv 2.) Engineering Fee Disclosure;3.)Authorization for Site Visits;4.)
Other Permit Responsibilities;5.)Official Meeting Disclosure and 6.)Agreement to provide documentation required.
OWNER's AGENT FORM Complete the following if tile OWNER of the property is not the Sallie as tile applicant:
Owner:—11 ausn �y�' �_ Ckx�,*ey-S 0r NCW '4u-VY-_ Uc
Designates; llI}'t>tgent regarding the following:
Variance Site Plan Subdivision
For Tax Mal)No.: Deed Ref qrcjljc- Book Page_Date
OWNE It SIGNATURE: DATE:
IVA A A JAd
VV V%--'%--
v
APPLICANI'S AGENT Fojm�*i' Cotnplele the following If file APPLICANT is unable to attend file
ug tu�
lueeting or wishes to be represented by another party:
c1d r/1,
Owner. it-PA•n -Fla -A/4"A,1 f—A*
A oz as Agent regarding(lie following:Designates: 3
I
............
Variance)K, Site Plan Subdivision
For Tax Map No.: D ed eference.- Book Page__Date t;
OWNER SIGNATURE* ATE: 12-9 1 24
2,) 9-.4G1NEE,1UNG FEE DISCLOW Applications may be referred to die Town consulting engineer for review of septic design,-slum,
drainage,etc.as determined by the Zoning or Planning Dep2riment. recs for engineering review services will be charged directly to the applicant.
f-'ecs for engimeering,review nrill not exceed S 1,000%vitho-ol notification 10 The aPPlicaul.
3j At T 101UZATION FOR SITE VISITS: By signing this page and submitting the application materials attached herein,the Owner,Applicant,
and hWherldicir agent(s)hereby authorize the zoning Board or Planning Board mid Town Staff to enter the subject propettics for the pulpose or
reviewing the application submitted.
4.1 (OTjjKR pE.RMIT RESPONSIBILITIES: Other perluits tray be required for construction or alteration activity subsequent to approval by the
Zoning Board or Planning Board. It is lite applicant's,responsibility to obtain any additional permits.
designated
5.) or-FICIAL MEETING MINUTES DlSC_LO91JRE. it is she practice of the Community Development Department to have a
stenographer tape record the proccedings,or incolings resulting front application,and mimics transcribed rroill those tapes eonsthtnes the official
record of all proceedings,
6.) AGRrENIE,NT TO PROW DE DOCUMENTATION REQUIRED: 1,tile undersigned,have thoroughly read and understand the instructions
for submission and agree to tile submission requirculclus,I acknowledge no construction activities sit-all be commenced prior to issuance of valid
perillit. I certify that the application,plans andsupporthig 1111flerials are a true and coluplete slaterucid/demliption of the existing conditions and the
work proposed,and that all work will be perfarinet) in accordance with tile approved plans and in collibrillance will)local z0fli'19 regulations. I
acknowledge that prior to occupying file facilities proposed,I or my agents,will obtain a cei tificate of occupancy as necessary. I also understand that
hive inny be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance Ora certificate of
occupancy
III yr ad and agree to the above.
Sigt fit Print Namic[Applicant] Datc signed
I)PI
"Gar"'agree
ppli: d Page 7
sigilat gent] Pri t N ne[ gent] It, 1,ue