Designated Attorney Signature Page
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 FORM:
Complete the following if the OWNER,of the property is not the same as the�19,1k
Designates: lica t
Owner: K L af" s 1 L t% C�(Iti l yti{I 1 1 k`]rhe l
As agent regarding: '\ Variance Site Plan f�Subdivision
For Tax Map No.: _Section Block Lot
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:
Designates:
As agent regarding: Variance _Site Plan _ _Subdivision
For Tax Map No.: Section Block Lot
Deed Reference: Book Page Date
OWNER SIGNATURE: DATE:
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$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 agen((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.
4.1 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.
6.1 AGREEMENT TO PROVIDE DOCUMENTATION REOUX&FID 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,1 or my agents,will obtain a certificate of occupancy as necessary. I also understand that
[Ave may be required to provide an as-built survey by a licensed land surveyor of all newly constructed facilities prior to issuance of a certificate of
occupancy
�Ihave reartd agree to t ` o,e, 1 f
�' [Applicant]
rSig Print Name [Applicant] Date signed
Signature [Agent] Print Name [Agent] Date signed
9
Site Plan Review application—Revised October 2016
Town of Queensbury Planning Office-742 Bay Road,Queensbury,NY 12804