HomeMy WebLinkAboutPA2023-0024_20230128_Discetionary Application Owners AffidavitPOR Community Development Department
Discretionary Application
Owner's Affidavit
CITY OF NEWPORT BEACH
100 Civic Center Drive
Newport Beach, California 92660
949 644-3200 UFO newportheachca.govlcommunitydevelopment ORNI
1. Check Permits Requested:
Approval-in-Concept -AIC #
Coastal Development Permit
Waliver for De Minimis Development
Coastal Residential Development
Condominium Conversion
Comprehensive Sign Program
Development Agreement
Development Plan
Lot Line Adjustment
Lot Merger
Limited Tem Pemit
Seasonal «90 day 90 days
Modification Pemit
Off-Site Parking Agreement
Planned Community Development Plan
Planned Development Permit
Site Development Review-
Major U Minor
Parcel Map
Staff Approval
Tract Map
Traffic Study
Use Pemit -Minor Conditionat
Amendment to existing Use Pemit
Variance
Amendment -Code OPC GP LCP
Zoning Clearance -ADU Use
Other
2 Project Address(es)/Assessor's Parcel No(s)_
417 Tustin Ave. Newport Beach, CA 92663 APN: 049-033-18
3. Project Description and Justification (Attach additional sheets if necessary): -
A remodel & A.D.U. addition for: David Olson & Lisa Worsch
4. Property Owner's Affidavit": (0 We) David Olson & Lisa Worsch
depose and say that (1 am) (we are) the owner(s) of the property (ies) involved in this application. () (We) further certfy,
under penalty of perjury, that the foregoing statements and answers herein contained and the infomation herewith
submitted are in all respecs trueend corect to the best of (my) (our) knowledge and belief.
Signature s Tte:Property OwnerDate:01/28/2023
MM/DDYEAR
Signature(s) Titdle:Property Owner Date:01/28/2023
May be Signed by the lessee or by an authorized agent if written authorization from the owner of the record is filed concurrently with the
application. Please note, the owner(s)' signature for Parcel/Tract Map and Lot Line Adjustment Application must be notarized.
"Under the Levine Act, Section 84308 of the Government Code, a party to a proceeding before the City invoving a license,
permit, or other entitlement for use is required to disclose on the record of the proceeding any contribution in an amount of
more than two hundred fifty dollars ($250) made within the preceding 12 months by the party or the party's agent to any
elected or appointed officer of the City. If you have made a qualitying contribution, please ensure to make this disclosure on
the record. Please review Senate Bill 1439 Statues 2022 for further information"
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