Cembrook-Agent-081220 Area Variance [ZBA approved: September 21 2016]
This page includes the 1.) Authorization to Act as Agent Form: 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 FORA: Complete the following if the OWNER of the property is not the same as the applicant:
Owner:
Designates: as Agent regarding the following:
Variance Site Plan_ Subdivision
For Tax Map No.: Deed Reference: Book Page Date
OWNER SIGNATURE: DATE:
APPLICANT'S AGENT FORM: Complete the following if the APPLICANT is unable to attend the
meeting or wishes to be represented by another party:
Owner: Kathy Sanders
Designates: Pam Cembrook as Agent regarding the following:
Variance_ Site PIan_ Subdivision
For Tax Map No.:289.97.1-42 Deed Reference: Book Page Date
OWNER SIGNATURE: f / DATE: 8/10/20
2.) ENGINEERING FEE DISCLOSURE: Applications may be referred to the Town consulting engineer for review 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 applicant. Fees for engineering review will not exceed S 1,000 without notification to the applicant.
3.) AUTHORIZATION FOR SITE VISITS: By signing this page and submitting the application materials attached herein, the
Owner, Applicant, and his/her/their agent(s)hereby authorize the Zoning Board or Planning Board and Town Staff to enter the subject
properties for the purpose of reviewing the application submitted.
4.) OTHER PERMIT RESPONSIBILITIES: Other permits may be required for construction or alteration activity subsequent to
approval by the Zoning Board or Planning Board. It is the applicant's responsibility to obtain any additional permits.
5.) OFFICIAL MEETING MINUTES DISCLOSURE: It is 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 the official record of all proceedings.
6) AGREEMENT TO PROVIDE DOCUIMENTATION REQUIRED: I, the undersigned, have thoroughly read and understand
the instructions for submission and agree to the submission requirements, I acknowledge no construction activities shall be
commenced prior to issuance of a valid permit. I certify that the application, plans and supporting materials are a true and complete
statement/description of the existing conditions and the work proposed, and that all work will be performed in accordance with the
approved plans and in conformance with local zoning regulations. I acknowledge that prior to occupying the facilities proposed, I or
my agents, will obtain a certificate of occupancy as necessary. I also understand that I/we may be required to provide an as-built
survey by a licensed Iand surveyor of all newly constructed facilities prior to issuance of a certificate of occupancy
I havq read and a ee to the above.
1"`-, `�� Kathy Sanders 8/10/20
S' re[Ap�ylica t Print Name [Applicant] Date signed
( � Pam Cembrook 8/10/20
Signature[Agent] Print Name[Agent] Date signed
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