Applicant Certification Statement for the Zoning Board of Appeals

Applicant Certification Statement for the Zoning Board of Appeals
Project Information
Project Location/Address*
Name of Authorized Agent*
Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Applicant Certification Statement
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 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 will provide the required neighborhood notification information and will provide the required documentation of said notice to the Department of Planning and Development at least five (5) days prior to the opening of the public hearing.
- 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 Board receipt of the application and provide documentation of said notice to the Department of Planning and Development prior to issuance of a decision.
- I understand the penalties for obtaining a permit through deception or through inaccurate or misleading information.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: