In authorizing the submission of this application, I hereby certify the following:

• The agent identified herein is authorized to act on my behalf regarding this application.
• I will send the required notices (if applicable) to the Department of Public Health and applicable water company/water supply system within 7 days of Commission receipt of the application and provide documentation of said notice to the Department of Planning and Development prior to issuance of a decision.
• I am familiar with the information contained in the application submissions and that such information is complete, true and correct to the best of my knowledge.
• I understand the penalties for obtaining a permit through deception or through inaccurate or misleading information.
• I understand that the subject application must comply with all applicable requirements of the Mansfield Zoning Regulations.
• I understand that the subject application will not be considered completed until the Property Owner of record completes and submits the Property Owner Certification Statement, available at https://mansfield-planningdevelopment-mansfield-ct.app.transform.civicplus.com/forms/13620.