PROPERTY OWNER’S

00263A

ACKNOWLEDGEMENT FORM

Subject Property (Address or APN(s): Application Type/Request

1. I am the property owner or have obtained the property owner’s / owners’ consent to the
submittal of this application and contents therein; and

2. I have carefully reviewed and prepared the application and plans in accordance with the
instructions and materials required on the applicable permit checklist; and

3. I provided correct and accurate information in this application, including all attachments;
and

4. I understand that the submittal of inaccurate or incomplete information or plans, or failure to

5. I understand that it is the responsibility of the applicant to substantiate the request through
the requirements of the application, including any required Findings (when applicable); and

6. I understand that upon further evaluation, additional

7. I understand that failure to submit any such required fees or information requested after
submittal may result in processing delays and/or denial of my application; and

8. I understand that it is the responsibility of the applicant or property owner to notify the Los
Angeles County (“County”) Department of Regional Planning (“County Planning”) any
changes to the project, including change in ownership, which may require additional
information/documents/reports and fees and may cause delay to the processing of the
project; and

9. I understand that if there is a zoning violation on the property, plan review may be delayed.
Any unpermitted structures or uses must either be removed or legalized as part of this
application; and

10. I understand that when applicable, 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; and
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11. I am the property owner or have obtained the property owner’s / owners’ consent and
expressly allow, authorize, and permit the County to enter and inspect the subject property,
with or without prior notice, to inspect, photograph, and/or process this application. No
additional permission or consent to enter upon the subject property is necessary or shall be
required. I further certify and warrant that I am authorized to and, hereby do, consent and
allow such inspections on behalf of each and all owners of the subject property; and

12. I understand that all materials submitted in connection with this application may become
public record subject to inspection and copying by the public. I acknowledge and
understand that the public may inspect and copy these materials and that some or all of the
materials may be posted on County Planning’s website. For any materials that may be
subject to copyright protection, or which may be subject to sections 5500.1 and 5536.4 of
the California Business and Professions Code, I represent that I have the authority to grant,
and am granting, the County permission to make the materials available to the public for
inspection and copying, in hardcopy or electronic format; and

13. I understand that denials will result in no refunds; and

14. I understand that County Planning staff is not permitted to assist the applicant or proponents
and opponents of a project in preparing arguments for or against the project; and

15. I understand that there is no guarantee – expressed or implied – that an approval will be
granted. I understand that such application must be carefully evaluated and after the
evaluation has been conducted, or the public hearing (if applicable) has been held, that
staff’s recommendation or decision may change during the course of the review based on
the information presented.

LOBBYIST STATEMENT

16. The County Lobbyist Ordinance (Ordinance No. 93-0031, County Code Chapter 2.160 et
seq.), effective May 7, 1993, requires certification that each person (or entity) who applies
for a County permit is familiar with the requirements of said Lobbyist Ordinance, and that all
persons acting on behalf of the applicant have complied and will continue to comply with the
requirements of the Lobbyist Ordinance throughout the application process. I hereby certify
that I have read and am familiar with the requirements of the County Lobbyist Ordinance. I
further understand that the making of this certification, and compliance with the Lobbyist
Ordinance, shall be a condition precedent to the granting of the requested permit.

Lobbyist Permit No.(s) if applicable: _____________________________________

OAK TREE CERTIFICATION (PURSUANT TO COUNTY CODE CHAPTER 22.174: OAK

17. Are there any oak trees on the subject property or next to the subject property?

Yes No
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If yes, please check one of the following boxes:

I certify that no activity will occur within five feet of any oak tree dripline (canopy) or within 15
feet of any oak tree trunk, whichever distance is greater. This applies to both oak trees
located on the subject property AND oak trees next to the subject property. All oak tree
dimensions, including trunk diameter and canopy, are accurately depicted on the plans, and
drawn to scale for verification.

Activity will occur within five feet of any oak tree canopy or within 15 feet of any oak tree trunk
and I have concurrently filed for an oak tree permit. All oak tree dimensions, including trunk
diameter and canopy, are accurately depicted on the site plan, and are drawn to scale.

REQUIRED SIGNATURE(S)*

I, the owner(s) of the subject property, have read, understand, and acknowledge the above, and
consent to the submission of this application.

Note: If the applicant signs for the owner(s), please submit a letter of authorization from the
owner(s) with original ink signature(s)

12/19/2023
SIGNATURE (REQUIRED) PRINT NAME DATE

SIGNATURE (REQUIRED) PRINT NAME DATE

SIGNATURE (REQUIRED) PRINT NAME DATE

If necessary, add additional signature pages

*Please note a change in ownership, applicant, or agent will require a new acknowledgment form.