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Home My WebLink AboutPA2022-0204_20221113_Discretionary Application Owner's AffidavitCommunity Development Department Discretionary Application Owner's Affidavit 1. Check Permits Requested: E;Zl' Approval-in-Concept -AIC # D Coastal Development Permit D Waiver for De Minimis Development D Coastal Residential Development D Condominium Conversion D Comprehensive Sign Program D Development Agreement D Development Plan D Lot Merger D Limited Term Permit - D Seasonal D < 90 day 0>90 days D Modification Permit D Off-Site Parking Agreement D Planned Community Development Plan D Planned Development Permit D Site Development Review -D Major D Minor D Lot Line Adjustment D Parcel Map 2. Project Address(es)/Assessor's Parcel No(s) CITY OF NEWPORT BEACH 100 Civic Center Drive Newport Beach, California 92660 949 644-3200 newportbeachca.gov/communitydevelopment D Staff Approval D Tract Map D Traffic Study D Use Permit -□Minor □Conditional D Amendment to existing Use Permit D Variance 0 Amendment -□Code OPC □GP □LCP D Zoning Clearance -□ADU D Use D Other: 1 11'1 a / cp_\ v1.,.<; WP 4'-b.?:,·t.'B\·llo ~, L--\ -{l. S \J\4 L,·olo ~ > kJ -12 -<)1-(, ~? '1½ v1.-S &ft:i i:f1 .. -'? -1.181 • l5 3. Project Description and Justification (Attach additional sheets if necessary): i~\)\Jt ~'t\~i1\'CI~ ~~ \/\h\1'<.,h \~ ettE.-r * --\ht, y'(l)~t"-\ \iV\{_ 4. Property Owner's Affidavit*: (I) (We) ,_I _,_~...,..\)Qf)c~..._t_.___D=---_0....,.\.s'-'-uY)__,__ ___________ ___, depose and say that (I am) (we are) the owner(s) of the property (ies) involved in this application. (I) (We) further certify, under penalty of perjury, that the foregoing statements and answers herein contained and the information herewith submitted are in all respects true and correct to the best of (my) (our) knowledge and belief. Signature(s): ~ Title: I Ow~ I Date: I ~ 1t ;0p_;L MM/DD/YEAR Signature(s): Title: ~--------~ Date: ~----~I ---------------- *May be signed by the lessee or by an authorized agent if written authorization from the owner of record is filed concurrently with the application. Please note, the owner(s)' signature for Parcel/Tract Map and Lot Line Adjustment Application must be 119tarized. PA2022-0204 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Orange On }J()\RJ<Y\W J 11.-\J 1.1.. before me, Christine Som, Notary Public (insert name and title of the officer) personally appeared '¥-o'ott t: \) · 0 \,'So'<) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENAL TY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature ____.C ..... ~-'----'-----'-"-'-........... Jam-"'---'------(Seal) e e e e e e o e ~ CHRISTINE SOM Notary Public • Caiifornia 2 Orange County ;; Commission # 2412515 - y Comm. Expires Aug 9, 2026 PA2022-0204