Planning for the Challenges Ahead Los Angeles County Department of Regional Planning This application must be submitted in person. For a submittal appointment, call 213 - 974 - 6438. THIS SECTION - STAFF USE ONLY Plan: Code Section Project No. Zone: Permit No. CSD: TOD: ESHA / SEA: RFS No. SA: N E W SD: 1 2 3 4 5 ZD: GB? Y N LID? Y N DT? Y N 1. Subject Property (Sujeto Propiedad) Assessor222s Parcel Number(s) Property Size (Gross Area in Acres) Property Address or Site Location Name of Business or Establishment (If Applicable): 2. Uses (Usos) Current: Proposed: Continued (Renewal) Previous Permit Number: Attach copy of Findings and Conditions if available. 3. Project Description (Proyecto) Describe project in detail. Attach additional page(s) if necessary. See Instructions/Checklist Check/Complete All That Apply: No Improvements Proposed Demolition Private Septic System Private Well New Building Construction (SF): New Impervious Surfaces (Paving, Roofs, Etc. - SF): Grading (CY) Cut: Fill: Import: Export: Balanced on Site Alcohol Sales: Beer & Wine or Full Line of Alcohol On-site Consumption or Off- site Consumption 4. Applicant (Solicitante) Name: Phone: Address: Fax: City/State: ZIP: Email: 5. Agent (Agente) If different from applicant American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 Name: Phone: Address: Fax: City/State: ZIP: Email: 6. Proper ty Owner(s ) (Due361o/a Registrado) If different from applicant Name: Phone: Address: Fax: City/State: ZIP: Email: 7. Owner / Applicant Certification (Certificaci363n del Solicitante, Agente o Due361o/a) By my signature below, I hereby certify the following: 1. I understand that it is the responsibility of the applicant to substantiate the request through the Findings. 2. I understand there is no guarantee - expressed or implied - that any permit will be granted. I understand that each matter must be carefully evaluated and after the evaluation has been conducted or the public hearing has been held. Staff222s recommendation or decision may change during the course of the review based on the information presented. 3. I understand that planning staff is not permitted to assist the applicant or opponents of the project in preparing arguments for or against a request. 4. I understand that the environmental review associated with the submittal of this application is preliminary, and that after further evaluation, additional information, reports, studies, applications and/or fees may be required. 5. I understand that if my application is denied, there is no refund of fees paid. 6. I understand that submitting inaccurate or incomplete information may result in delays or denial of my application. 7. I certify that the information provided in this application, including attachments, is accurate and correct to the best of my knowledge. 8. I have read and understand the foregoing, and agree to the submittal of this application. Signature (Blue Ink): Date: Print Name: Check One: Owner Applicant 8. Oak Tree Certification (Certificaci363n de 301rboles Robles) (Pursuant to Chapter 22.174) Check only one box below: By my signature below, I certify that there are no oak trees or oak tree protected zones (five feet from the drip line of the canopy or within 15 feet of any oak tree trunk, whichever distance is greater) located on the subject property or properties. By my signature below, I certify that there are oak trees or protected zones (five feet from the drip line of the canopy or within 15 feet. of any oak tree trunk, whichever distance is greater) within the subject property or properties, but that no work will be done within these protected areas. This applies to on and off-site oak trees. All oak tree dimensions, including trunk diameter and canopy, should accurately be depicted on the plans and be drawn to an acceptable scale. By my signature below, I certify that project activity will occur within the protected zone of an oak tree (five feet from the drip line of the canopy or within 15 feet of an oak tree trunk) and that I have concurrently submitted an Oak Tree Permit application. All oak tree dimensions, including trunk diameter and canopy, a re accurately depicted on the plans and drawn to an acceptable scale. Signature (Blue Ink): Date: Print Name: Check One: Owner Applicant Agent 9. Santa Monica Mountains Local Coastal Program (Programa Local Costero de las Monta361as de Santa Monica) (Pursuant to Chapter 22. 44.600 et seq. ) ( Complete only if project is within the Santa Monica Mountains Coastal Zone) Check only one box below: It is my understanding that this proposed development project is EXEMPT from the LIP pursuant to Section 22.44.820, and I have attached all of the material required in the LIP Exemption Determination Checklist. It is my understanding that this proposed development project requires a Coastal Development Permit (CDP) pursuant to the LIP, and I have attac hed all of the material required in the Santa Monica Mountains Local Coastal Program CDP Checklist. Signature (Blue Ink): Date: Print Name: Check One: Owner Applicant Agent 10. Lobbyist Statement (Informaci363n de un Grupo de Presi363n) The Los Angeles County Lobbyist Ordinance, effective May 7, 1993, requires certification that each person who applies for a County permit is familiar with the requirements or Ordinance No. 93-0031 (Lobbyist Ordinance), and that all persons acting on behalf of the applicant have complied and will continue to comply with the requirements of said Ordinance through the application process. By my signature below, I hereby certify that I am familiar with the requirements of Ordinance No. 93-0031 and understand that making such a certification, and compliance with this ordinance, shall be conditions precedent to gran ting the permit requested, license, contract or franchise. Signature (Blue Ink): Date: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 Print Name: Check One: Owner Applicant Agent Lobbyist Permit Number, If Applicable: The information requested is required for a Zoning Permit, Coastal Development Permit, and Oak Tree Permit, pursuant to Title 22 of LA County Code. Failure to provide complete and accurate information will cause delay. All required supplemental information must be submitted with this application. Additional application forms are available at: http://planning.lacounty.gov/apps. See instructions and checklist . For assistance, call 213-974-6411 or click http://planning.lacounty.gov/who . IF YOU SUSPECT FRAUD OR WRONGDOING BY A COUNTY EMPLOYEE, PLEASE REPORT IT TO THE COUNTY FRAUD HOTLINE AT 1-800-544-6864 OR WWW.LACOUNTYFRAUD.ORG . Y OU MAY REMAIN ANONYM OUS . THIS SECTION - STAFF USE ONLY 226 LDCC COMMENTS Rev03/2019 American LegalNet, Inc. www.FormsWorkFlow.com