HomeMy WebLinkAboutPA2023-0080_20230410_Owner's AffidavitCommunity Development Department
Discretionary Application
Owner's Affidavit
1. Check Permits Requested:
] Approval-in-Concept -AIC #
] Coastal Development Permit
D Waiver for De Minim is Development
] Coastal Residential Development
] Condominium Conversion
] Comprehensive Sign Program
] Development Agreement
J Development Plan
0 Lot Merger
0 Limited Term Permit -
D Seasonal D < 90 day 0 >90 days
0 Modification Permit
0 Off-Site Parking Agreement
0 Planned Community Development Plan
0 Planned Development Permit
0 Site Development Review -
D Major D Minor
J Lot Line Adjustment O Parcel Map
2. Project Address(es)/Assessor's Parcel No(s)
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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
Iii Use Permit -[j)Minor □Conditional
0 Amendment to existing Use Permit
0 Variance
D Amendment -□code dPc □GP □LCP
D Zoning Clearance -□ADU D Use
0 Other:
3. Project Description and Justification (Attach additional sheets if necessary):
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4. Property Owner's Affidavit*: (I) (>Ne) I 0 \ Q\Y\a:hHe se ( V" c-e s J (2 Ca . Co( p . I
depose and say that (I am) (we are) the owner(s) of'the property (ies) involved in this application. (I) (>Ne) further certify,
under penalty of perjury, that the foregoing statements and answers herein contained and the information herewith
submitted are i II respects and co to the best of (my) (our) knowledge and belief.
Signature(s):, .:,,=-+i---1--=~,-=,-c.....:...;:::~--'-9'~~ Title: I CO yv\.6 \ 1 ev-
Signature(s): ______________ Trtle: ... I _________ ....,I Date: ..... I _____ __,I
"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
pplication. 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 involving a license,
rrnit, or other entitlement for use is required to disclose on the record of the proceeding any contribution in an amount of
re than two hundred fifty dollars ($250) made within the preceding 12 months by the party or the party's agent to any
~lected or appointed officer of the City. If you have made a qualifying contribution, please ensure to make this disclosure on
' e record. Please review Senate Bi/11439 -Statues 2022 for further information"
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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:
________________________________________________________________________________________