HomeMy WebLinkAboutPA2023-0086_20230417_Discretionary Application Owners AffidavitCommunity Development Department
Discretionary Application
Owner's Affidavit
1. Check Pemiitl! Requested:
D Approval-in-Concept -A!C #
D Coas1al Oevelopmonl Permit
D Wa\ver for De Min\m\s Development
■ Coas1al Residential Development
D Condominium Conversion
D Comprehensive Sign Program
D Development Agreement
D Development Plan
D LotMerger
D limited Term Permit•
0 Seaaonal D < 90 day 0>90 clays
D Modification Permit
D Off-Site Parldng Agneemant
D Planned Community Development Plan
D Planned Development Permit
D Srte Development Review -
D Major D Minor
D Lot line Adjustment D Parcel Map
2. Project Address(es)/AsseHor's Paree! 1\10(11)
1106 Amethyst Ave, 050-171-10
100 Civic Center Drive
Newport Beach, Gali!omia 92660
949 644-3200
newportbeachca.gov/communltydevalopmant
D Staff Aoproval
□Tract Map
D Traffic Study
0 Use Permit ~□Minor 0Condltiona!
D Amendment to existing Use Permit
D Variance
□ Amendment -□Code □PC □GP □LCP
D Zoning Clearance -□ADU □ Use
D Other:
3. Project Description and Jmtiflcatioo (Attach additimal sheem if necenary):
Add 800 S.F. accessory dwelling unit in existing 2nd floor covered balcony area. This wili
provide independent housing for a family member.
4. Property Owner's Affldavtt•: (I) (We) i J O ~::, J2. , ilc.cC~7 -'--J ! _________ __,
dep~ and say thlll (I am) <-am) the ~8f(s) of the i:roperty (ies) ln1/0i\led il1 this application. (I) (We) furthar certify,
under penalty of perjury, tiat the li:lregl:ling sta!emen!s and l!Dswera herein coo!eined and the i11fumlalio11 herewith
submitted am in all respecill-lm€.and rom,ct lo the bes! of (my) (our) knowledge end belief.
Signab.Jra(s): _/....c..~-·_-:_~,.,._:_·~_·. _·._._ .. -c, __ · _______ Trt!e: I \v'\ '\ 1 c. 5 (:°
<·;'.>" MM/DD/YEAR
,..,/~ 1 I
Signa1ura(s): ______________ TIiie: c.l _________ _,·Date:,._, _____ __,
*May be !Signed by the lessee or by an authori:Zed agent if written authorization from the owner of the record is filed concurrently wm, the
application. Plea!le note, the owner(s)' signature for Parcel/Tract Map and lot Une Adjustment App!ication must be notarized,
"Under the Levine Act Section 84308 of the Government Code, a party io a proceeding before the City involving a license,
permit or other entitlement for use is requif9d to disclose on the f9cord of the proceeding any contribution in en amount of
more than two hundred fffty dollars ($260) made within the pf9C8ding 12 months by the party or the psrty'11 agent to any
elected or ttppointed officer of the City. If you have made a qua/lying oontnbution, plea1te ensure to make this disclosure on
the record. P1es11e review Senate 8111 1439 -Statues 2022 for further information"
\\crib .k'.l\data\Usarn\CDD\Sharnd\Adm!n\Plann!ng_ DMslon\Appl!c:iUons\A{.)pl!ca1lon _ Guldel!nes\P!ann!ng P~rmlt Owner•~ Afl'arlavlt 2022 .doe: Rev: 01/24123
I:\Users\CDD\Shared\Admin\Planning_Division\Current_Templates\Office Use Only Form Updated 01/27/2020
2700-5000 Acct.
Deposit Acct. No. ________________________
For Deposit Account:
Fee Pd: _______________________________________
Receipt No: ____________________________
FOR OFFICE USE ONLY
Date Filed: _______________________
APN No: __________________________
Council District No.: _________________
General Plan Designation: ____________
Zoning District: _____________________
Coastal Zone: Yes No Check #: __________
Visa MC Amex # ____________
CDM Residents Association and Chamber
Community Association(s): _______________________ Development No: __________________________
_____________________________________________ Project No: ________________________________
_____________________________________________ Activity No: _______________________________
Related Permits: ___________________________
Remarks:
________________________________________________________________________________________