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492, Master bedroom addition and en, ApplicationThe undersigned 4)IbsS0 Street Address !SUES? FOR HEARING FOR ZONE VARIANCE CITY OF ROLLING HILLS I /Mv7 INA Name (alb) 544 ,177-7 Telephone Number (1) is/are the owner(s) or is/are in lawful possession of (2) has permission of the owner Legal description of property Situated at Lot Tract ) VALINMSeftr LA1111 Street Address Describe in detail the nature of the proposed use, including what aspects of the . project require a Variance. • MST- OP- � MAD M» �XI�I�Cr rikAT s Criteria to be satisfied for grant of Variance Such change is based upon the following described exceptional or extraordinary circumstances or conditions that do not apply generally to other property in the 'same vicinity and zone. 7 I\D Pl ra- 7t1C f - 2 WP'c`f t6 AL436kby C.,tr- Such change will not be materially detrimental to the public welfare nor injurious to the property or imn-nvements in such vicinity and zone where property -is located because. M5 Rase. AlteriA Viv f s s ltkE t n iz- .,NIz J Tr f lb AL IA UID ! mukkmAL, t A it • FILING FEE A f i l ina top • i • PROPERTY OWNER: OWNERS ADDRESS: TELEPHONE NO: PROPERTY ADDRESS: REOU$8T FOR BEARING FOR SITE PLAN REVIEW CITY OF ROLLING HILLS (%eCX,1 4 r\ MAA W (UU Atl1S 126- LAE.- J E • 41•227n vof-k • 919•10e0 WILUANk p5uf L .. LEGAL DESCRIPTION: LOT NO ASSESSORS BOOR NO PAGE PARCEL' AGENT'S NAME: AGENT'S ADDRESS: TELEPHONE NO: ************************************************************** ******* NATURE OF PROPOSED PROJECT Describe in detail the nature of the proposed project, including what aspects of the project require a Site Plan Review: A 5r t TLAfi I 1 leafzeputrED 5Act,'K t. j -rtbli 1 2'0, or -ram. Mgt n& UIltilh /lex, -tom. Am -nark 6 F L 'n) MissiEf tope AnD m►% A t VsfAILXIQFSaM to . n srtnU 2FAAW(/E AfEA. SITE PLAN REVIEW CRITERIA Site plan review criteria upon which the Planning Commission must make an affirmative finding. Describe in detail the project's conformance with the criteria below: A. Is the project compatible with the General Plan, the Zoning Ordinance and surrounding uses? Explain how it compares to the sizes, setbacks and other characteristics of neighboring houses. rfi leg- la sirkIL - 11 s1Zt.1?) tat - i iiiv lb b sn T \ DLA-TE. isoW s reAct u MErcir7.1 AffedivrircgAL 'ITf L rMD ust. c,itmscsr t\T harm a M - wit Site Plan Review Application -9- 0• B. How does the project preserve and integrate into the site design, to the maximum extent feasible, existing natural topographic features of the lot including surrounding native vegetation, mature trees, drainage courses, and land forms (such as hillsides and knolls) ? Explain how the project preserves and integrates existing natural features. i VAL PAVE MOW-- . %rig on E t5j1f1Cs T\ its SE E,. "TlefrE. WILL 16E. r GPM& D$ tM&E. PA.-NEW-7 MU- Ng" BE. i ikD 66 MT:4, Ale lb E . C. How does the site development plan follow natural contours of the site to minimize grading? Extensive grading and recontouring of existing terrain to maximize buildable area shall not be approved. Graded slopes shall be rounded and contoured so as to blend with existing terrain. Grading shall not modify existing drainage redirect drainage flow unless into an existing drainage course. Explain the nature and extent of the impact of grading and proposed minimization on lots. 11-T_ f'4?-6..Nraff tliST fauNIft., 6rAtoll,r. D. To what extent does the site development plan preserve surrounding native vegetation and supplement it with landscaping that is compatible with and enhances the rural character of the community? Landscaping should provide a buffer and transition zone between private and public areas. Explain how the project preserves native vegetation, integrates landscaping and creates buffers. lift) t - r SAl Nltr WU- .i2EMNE.b Or. Ar ' .b Enc -Avv, - mkt %3wiEwhi fular-th6- 6#42716e„ --)trottAbrti otitikE12- suwan ilLT 61N AW'r h&O L Site Plan Review Application -10- 0• • • E. How does the site development plan preserve the natural and undeveloped state of the lot by minimizing building coverage? Lot coverage requirements shall be regarded as maximums and the actual amount of lot coverage permitted should depend upon the existing buildable area of the lot. Explain how the lot coverage proposed compares with lot coverage square footage and percentages on neighboring lots. "Mt Lt3r CtsV t-sr. tAmmtvarz, , I&UA tSf 1Y-AAG- AR 1 ! 4S . T+t.t. Easroak, ositAs &.r- F. Is the site development plan harmonious in scale and mass with the site, the natural terrain and surrounding residences? Setbacks shall be regarded as minimums and more restrictive setbacks shall be imposed where necessary to assure proportionality and openness. Explain how the proposed project setbacks compare with the existing setbacks of neighboring properties. Chotab1 M T> PC r.1Ai Ml_ Is tN-Aolettz - W vnc rvz- A YmminAV W ,fin.& rra 6f 1 W . XI W - l& 114Autrxieb A 1D ,A catQ Yir (i / t PA - G. Is the site development plan sensitive and not detrimental to convenience and safety of circulation for pedestrians and vehicles? Explain how the number and types of vehicles relate to the driveway location, design, trip data, landscaping and other on -site parking or storage areas. ?MEV-4N\ Mb VEk tc1 l - rrtc Aft t )h, ffecrED. Site Plan Review Application -11- i• O. H. Does the site development plan conform with the requirements of the California Environmental Quality Act? Explain how the project impacts the environment, e.g. significant impact, proposed mitigation measures. 71144, 1 "c-4511111A v rn 11 cAU ik Emitt 110 L.. Lrf ACT ItD WILL. AVE Sv tre A CT lM ' I hereby certify that the statements furnished above, and in attached exhibits, presents the data and information required for the site plan review criteria evaluation to the best of my ability; and, that the facts, statements and other information presented are te and correct to the best of my knowledge and belief. Date: /- 93 Signature For: Applicant Site Plan Review Application -12- 0• OWNER'B DECLARATION I (We) declare under penalty of perjury that the foregoing is true and correct. Executed at Hi (.,(, 5 , California, U this day of /='-C'16 , 199,E 0 (address) NOTE: The Owner's Declaration can only be used if this application is signed in California. If this application is signed outside of California, the applicant should acknowledge before a Notary Public of the State where the signature is fixed, or before another officer of that State authorized by its laws to take acknowledgements, that he (it) owns the property described herein, and that the information accompanying this application is true to the best of his (its) knowledge and belief. Attach appropriate acknowledgment here. APPLICANT: DATE FILED 2////3 REPRESENTATIVE: 1Y/LT9A E: (,�i�0 / Q/ 4- (Z,Sb /6t Qaa) COMPANY NAME: RECEIPT NO: KAW COMPANY ADDRESS :1 cipvimM ecob. BY: _TOITAActioulDfilok ogxv ZONING CASE NO: oz. COMPANY PHONE NO 1 7t b) tot&aVot TENTATIVE HEARING DATE: 3' PROJECT ADDRESS:') IACJA AS& LArtt. Site Plan Review Application -13- 00 OWNER'S ACKNOWLEDGEMENT Property development in Rolling Hills is governed by ordinances of the City of Rolling Hills ("City") and by private deed restrictions enforced by the Rolling Hills Community Association ("RHCA"). The land development permit process of the City and the RHCA are completely independent and separate. Both must be satisfied and approval given by both the City and the RHCA to develop property in Rolling Hills. An approval by either the City or the RHCA does not mean or imply or ensure approval by the other. The suggested sequence of property development is to obtain City approvals first. I, (We), the undersigned, acknowledge that the above statement has been fully read and its admonition is completely understood. Executed at jQ CL '.Jd_ 0 1 LL y , California this r µ 5 7i day of j-t- f j , 19, By: By: Address 1-6U 1r117. RILLS City Site Plan Review Application -14- • CITY OP ROLLING HILLS TONING CASE CERTIFIED PROPERTY OWNER'S LIST AEFIDAVI! STATE OF CALIFORNIA COUNTY OF LOS ANGELES SS I, , declare under penalty of perjury that the attached list contains the names and addresses of all persons to whom all property is assessed as they appear on the latest available assessment roll of the County within the area described and for a distance of one thousand (1,000) feet from the exterior boundaries of property legally described as: Executed at /D L LJ •v c //i tLS this i day of F-th .- SIGNATURE Conditional Use Permit Variance Site Plan Review Zone Change Site Plan Review Application -15- (�l , California, , 19 M ,, 101.r� / Vicinity Map scale 1" = 800' 253 y :I 4;;.. .ei'+'+r,1 I.7 ;; T -. \.+ te.r .�., /ce./a/ \'ti:i'%/\//i :/1 ......'.-/ �-- / /I\\, Ors / 1 .. ' ' / / '. \ r ... 1. / rote:/j /"1\ s9•e \\0.1:1 / 'tip�i) ` a 1 !0 d. ii a WI... I ! 96 \(fA \•\ r I i ...... \; I /�\ J I \ iu i I \` \ Rw ...., I I 'J.\ i I / p I I la•C \ \ I,r1 /__i,'_ \\) 11;..•1 toe-, , •".\�•_/ /; »'« 1. ' .°./0..°.. �" \ ' / bP,6 • \\ 1 1 1 M \\ 1 p'L- ---� •c, "1 P'uaA 11 \\�\ tr1�� //1\\ • A..>r.� ,1 \Y� : 6ON. ' r•�11,' A .a itI 7 7' `11 1 / r • -^J/ •.�.... \\ \x.°`o..+°: �\ //0•' 1, �6144. PR. 150.-0 L---- I _L I I F. • rmw • / \ III //i .//.- i _ 1 ., I ,- - -'- ` . , / //f a' II n I•. •.• ili twn..� 1 ,\ N N, II�S--,\t-I. \ ,,--`--\\t-S jate/. ` '";. ) i • • /02 u» r • ,144 topp, .\ + r �� 11!w' ,tea, ^/ry I ` / w � 3 ` is ' • .. • ,,.r4 rA ( J.. A:. �' 1 e'.i //' : ','., :tt lxY';' i r 4. ..y,... JJ l . /e / 4,9 ,LL' I \ 'w•{w 1 "'J. Y7 / , . I / + \ /f ,4 ‘\ /..-- "... I t do i\ \` ; - �_in✓-I 1I , .N, 1 4 ' rt,r... •} ' ,\1•I i _ ,;i /\\fin.rN '\ O ;I l .`'u. . / s• fi� r I It_ i•• � l6}Li/ �_� s6 1` \v --fO� // I I —!/ n) :\\\\ • I -\r J ,_1 y r 69 I. t 6 =;iQ:a I I i t •-i \ \ 72N ry ram» �nGT rl :�Ji) -- % _ M 67 'ill OR /50•A i S:n++ • •/Jt'AG 1rr a..c�\\�; »•e Y : ss ti11::r RAC ` /26•C JON N e r^ r 1 v 1 / I i o' 1 <..,, /.. �� Ito .• /. ' / /'1 \„1'% 90,0 new'• •• ^. \ \ 1741 96 ..,._ / 1 1 \I , ; ..:.:,.t.p•r .p..y: ,, .7.4 irlitv:W::, ....1 ,,,,,,...... ......... .; LII 1 .7..:°. ' '''' . t. ‘1;:: i: ,s%., / RIj�150 AO +o ' ;P.. ._. • I • C W'fOrl / 6 / / J., w / i.• ul•i,t 1+ am2 n1• '0'1 Jr5 • 41 • DATE BUILDING AREAS NET LOT AREA BUILDING PAD(S) RESIDENCE GARAGE SWIMMING POOL/SPA STABLE RECREATION COURT ( ) SERVICE YARD c(W) ZONING CASE NO. TOTAL STRUCTURES % STRUCTURAL COVERAGE % PAD COVERAGE DRIVEWAY PAVED WALKS S. PATIO AREAS POOL DECKING TOTAL FLATWORK % TOTAL FLATRORK COVERAGE TOTAL STRUCTURAL & FLm0RK COVERAGE % TOTAL COVERAGE CALCULATION OF EXISTING 1$j4sq.ft. 1 5sq.ft. 2.5eSsa.ft. (D(ot sq. ft. 1 V2.sq.ft. IRIS sq.ft. 221S sq.ft. sq.ft. 46-0 sq.ft. 2.c c sq.ft. ¥Lb sq.ft. 81S sq.ft. (o$1S sq.ft. 8.% 14 t2 sq.ft. ,2 % ADDRESS WluJ FJJy 1NE APPLICANT WOW LOT COVERAGE PROPOSED sq.ft. sq.ft. sq.ft. sq.ft. sq.ft. sq.ft. IIMMA MOP son sq.ft. sq.ft. sq.ft. sq.ft. TOTAL 76,477sq. ft. l9 iiSsq.ft. 3PlSsa.ft. WW2 sq.ft. 511- sq.ft. ?-16-sq.ft. 221S sq.ft. sq.ft. 456sq. ft . sq.ft. ?23D sq.ft. '32k sq.ft. 2?S8(P sq.ft. sq.ft. &h. sq.ft. 32� sq.ft. 4401,4 sq.ft. 44611 8.1 % terv:4 sq.ft. sq.ft. 19 .c) % • • • DATE ZONING CASE NO. ADDRESS 41 Ntii..iNA.P6U `6 - fie APPL I CANT l In Y1 CALCULATION OF BUILDING PAD'rRAGE PAD NO. 1 BUILDABLE PAD AREA tbf�_sq.ft. RESIDENCE 1,F1S sa.ft. GARAGE sa.ft. STABLE (BARN) sq.ft. POOL 512_ sq.ft. RECREATION COURT TOTAL STRUCTURES ON PAD NO. 1 4, sq.ft. 4156 sq.ft. sq.ft. % BUILDING PAD COVERAGE 25►6 $ PAD NO. 2 BUILDABLE PAD AREA RESIDENCE sq.ft. GARAGE sq.ft. STABLE (EARN) sq.ft. POOL sq.ft. RECREATION COURT sq.ft. OTHER sq.ft. TOTAL STRUCTURES ON PAD NO. 2 sq.ft. % BUILDING PAD COVERAGE -8- i• •• City O/ /1E'O/fLfl ...Jh/LS INCORPORATED JANUARY 24, 1957 ENVIRONMENTAL INFORMATION FORM_ (To Be Completed By Applicant) Date Filed GENERAL INFORMATION NO. 2 PORTUGUESE BEND ROAD ROLLING HILLS, CALIF. 90274 (213) 377-1521 FAX: (213) 377.7288 Zoning Case No. 1. Applicant, address and telephone no. PI, 2. Legal Owner, address and telephone no. (if different from above) 3. Address of project 4) VAUUVUMAIrer Lilt. Assessor's Book, Page, Parcel No. Lot No. ink 4. List and describe any other related permits and other public approvals required for this project,including those required by city, regional, state and federal agencies:_ 5. Existing zoning district 6. Proposed use of site (project for which this form is filed): _,fit rtL '('b fi-ZCI'`-1111�l- S111M_ 'ID fV PROJECT DESCRIPTION 7. Site size 8. Net lot area 1641 644 9. Total square footage of structures y 18'y ST. 10. Number of floors of construction ONE.. -1- 4. irtr,n •• •• 11. Basement square footage Mi/A 12. Total combined flatwork and structural lot coverage it• 13. Will any exterior walls be removed or relocated?ich walls? VIE a ' t E tqr l‘bfilk. POD of 0 14. Will any interior walls be removed or relocated?hich walls? Site 10--t1t w vr'ur 12a04 klkb Ift STIPA AT Inv- efrzatay 15. Will the entire building structure require a new roof? i 16. Will the existing roof remain intact, with less than 200 square feet added? nis 17. Will cut and fill be balanced? A/A Amount cut '(1/ek Amount fill 11 / 1 18. If residential, include the unit size, approximate sale price and household size expected. 19. If commercial, indicate the type of project, whether neighborhood, city or regionally oriented, square footage of sales area, estimated employment per shift and loading facilities. tl/Pt 20. If this is industrial project indicate the type of project, estimated employment per shift, and loading facilities. //A 21. If institutional, indicate the major function, estimated employment per shift, estimated occupancy, loading facilities, and community benefits to be derived from the project. I\Pc 22. Attach plans.. 23. Proposed scheduling. 6Z5Y1. 1,5,7 'j' 116t r, 24. If the project involves a variance, conditional use or rezoning application, state this and indicate clearly why the application is required. hIsheRautivo Are the following items applicable to the project or its effects? Discuss below all items checked yes (attach additional sheets as necessary). Yes No lk 25. Change in existing features of any bays, tidelands, beaches, lakes or hills, or substantial alteration of ground contours. 26. Change in scenic views or vistas from existing residential areas or public lands or roads. - 2- . • • • 27. Change in pattern, scale or character of general area of project. 28. Significant amounts of solid waste or litter. 29. Change in dust, ash, smoke, fumes, or odors in vicinity. 30. Change in ocean, bay, lake, stream or ground water quality or quantity, or alteration of existing draining patterns. 31. Substantial change in existing noise or vibration levels in the vicinity. 32. Site on filled land or on slope of 10 percent or more. 33. Use or disposal of potentially hazardous materials, such as toxic substances, flammable or explosives. 34. Substantial change in demand for municipal services (police, fire, water, sewage, etc.). 35. Substantially increased fossil fuel consumption (electricity, oil, natural gas, etc.). 36. Relationship to a larger project or series of projects. ENVIRONMENTAL SETTING 37. Describe the project site as it exists before the project, including information on topography, soil stability, plants and animals, and any cultural, historical or scenic aspects. Describe any existing structures on the site, and the use of the structures. Attach photographs of the site. Snapshots or polaroid photos will be accepted. Tar_ e2CtsnN1b-- tk61iS$ AA FOLDtn. PAD A fADDt -iE n t5 cart' 14174,.E ! AM caffik. L h4 -A d - it ,-mt.isA art Nit 1 -16- , n { / r t4 . sry kT -tom.. F-1> or A ail -.DE # w 11006t4lam-. -3- �i 0• 38. Describe the surrounding properties, including information on plants and animals and any cultural, historical or scenic aspects. Indicate the type of land use (residential, commercial, etc.), intensity of land use (one -family, guest house, office use, etc.) and scale of development (height, frontage, set -back, rear yard, etc.). Attach photographs of the vicinity. Snapshots or polaroid photos will be accepted. u snttn& terelistzTV7 f-IEGIDEffriAL, llat fMt1( vAtkir AtE is VT( (9364.E. VME tAsettren en M.Wki, - Lkite. Are s tft ENVIRONMENTAL IMPACTS (Please explain all "yes" and "maybe" answers on separate sheets.) YES MAYBE NO 39. Earth. Will the proposal result in: a. Unstable earth conditions or in changes in geologic substructures? 4( b. Disruptions, displacements, com- paction or overcovering of the soil? -k c. Change in topography or ground surface relief features? d. The destruction, covering or modification of any unique geologic or physical features? e. Any increase in wind or water erosion of soils, either on or off the site? f. Changes in deposition or erosion of beach sands, or changes in siltation, deposition or erosion which may modify the channel of a river or stream or the bed of the ocean or any bay, inlet or lake? g. Exposure of people or property to geologic hazards such as earth- quakes, landslides, mudslides, ground failure, or similar hazards? -4- 0• •• 40. Air. Will the proposal result in: a. Substantial air emissions or deterioration of ambient air qaulity? b. The creation of objectionable odors? c. Alteration of air movement, moisture or temperature, or any change in climate, either locally or regionally? 41. Water. Will the proposal result in: a. Changes in currents, or the course or direction of water move- ments, in either marine or fresh waters? b. Changes in absorption rates, drainage patterns, or the rate and amount of surface water runoff? c. Alterations to the course or flow of flood waters? d. Change in the amount of surface water in any water body? e. Discharge into surface waters, or in any alteration of surface water quality, including but not limited to temperature, dissolved oxygen or turbidity? f. Alteration of the direction or rate of flow of ground waters? g. Change in the quantity of ground waters, either through direct additions or withdrawals, or through interception of an aquifer by cuts or excavations? h. Substantial reduction in the amount of water otherwise available for public water supplies? i. Exposure of people or property to water -related hazards such as flooding or tidal waves? -5- YES MAYBE NO 4( • • •0. j. Significant changes in the temperature, flow, or chemical content of surface thermal springs? YES MAYBE NO 4t 42. Plant Life. Will the proposal result in: a. Change in the diversity of species, or number of any species of plants (including trees, shrubs, grass, crops, microflora and aquatic plants)? i1K b. Reduction of the numbers of any unique, rare or endangered species of plants? c. Introduction of new species of plants into an area, or in a barrier to the normal replenishment of 41K existing species? d. Reduction in acreage of any agricultural crop? 43. Animal Life. Will the proposal result in: a. Change in the diversity of species, or numbers of any species of animals (birds, land animals including reptiles, fish and shellfish, benthic organisms, insects or micro - fauna)? b. Reduction of the numbers of any unique, rare or endangered species of animals? c. Introduction of new species of animals into an area, or result in a barrier to the migration or move- ment of animals? d. Deterioration to existing fish or wildlife habitat? 44. Noise. Will the proposal result in: a. Increases in existing noise levels? b. Exposure of people to severe noise levels? -6- �! •• YES MAYBE NO 45. Liaht and alare. Will the proposal produce new light or glare? 46. Land Use. Will the proposal result in a substantial alteration of the present or planned land use of an area? 47. Natural Resources. Will the proposal result in: a. Increase in the rate of use of any natural resources? b. Substantial depletion of any nonrenewable natural resource? 48. Risk of Unset. Will the proposal involve: a. A risk of an explosion or the release of hazardous sustances (including, but not limited to, oil, pesticides, chemical or radiation) in the event of an accident or upset conditions? b. Possible interference with an emergency response plan or an emer- gency evacuation plan? 49. Population. Will the proposal alter the location, distribution, density, or growth rate of the human population of an area? 50. Housina. Will the proposal affect existing housing, or create a demand for additional housing? 51. Transportation/Circulation. proposal result in: a. Generation of substantial additional vehicular movement? Will the b. Effects on existing parking facilities, or demand for new parking? c. Substantial impact upon existing transportation systems? -7- 1� •• Yes Maybe No d. Alterations to present patterns of circulation or movement of people and/or goods? 4( e. Alterations to waterborne, rail or air traffic? f. Increase in traffic hazards to motor vehicles, tit 52. Public Services. Will the proposal have an effect upon, or result in a need for new or altered governmental services in any of the following areas: a. Fire protection? b. Police protection? c. Schools? .( d. Parks or other recreational facilities? dk e. Maintenance of public facilities, including roads? "Nlk f. Other governmental services? 53. Eneray. Will the proposal result in: a. Use of substantial amounts of fuel or energy? qe b. Substantial increase in demand upon existing sources of energy, or require the development of new sources of energy? 54. Utilities. Will the proposal result in a need for new systems, or substantial alterations to the following utilities: a. Power or natural gas? b. Communications systems? c. Water? d. Sewer or septic tanks? e. Storm water drainage? -8- •• f. Solid waste and disposal? 55. Human Health. Will the proposal result in: a. Creation of any health hazard or potential health hazard (excluding mental health)? YES MAYBE NO b. Exposure of people to potential health hazards? t 56. Aesthetics. Will the proposal result in the obstruction of any scenic vista or view open to the public, or will the proposal result in the creation of an aesthetically offensive site open to public view? 57. Recreation. Will the proposal result in an impact upon the quality or quantity of existing receational opportunities? 58. Cultural Resources. a. Will the proposal result in the alteration of or the destruction of a prehistoric or historic archeological site? b. Will the proposal result in adverse physical or aesthetic effects to a prehistoric or historic building, structure, or object? 4,C c. Does the proposal have the poten- tial to cause a physical change which would affect unique ethnic cultural values? d. Will the proposal restrict existing religious or sacred uses within the potential impact area? d� •• 4110 59. Mandatory Findinas of Significance. a. Does the project have the poten- tial to degrade the quality of the environment, substantially reduce the habitat of a fish or wildlife species, cause a fish or wildlife population to drop below self- sustaining levels, threaten to eliminate a plant or animal commun- ity, reduce the number or restrict the range of a rare or endangered plant or animal or eliminate important examples of the major periods of California history or prehistory? b. Does the project have the poten- tial to achieve short-term, to the disadvantage of long-term, environ- mental goals? (A short term impact on the environment is one which occurs in a relatively brief, definitive period of time while long-term impacts will endure well into the future.) c. Does the project have impacts which are individually limited, but cumulatively considerable? (A project may affect two or more separate resources where the impact is relatively small, but where the effect of the total of those impacts on the environment is significant.) d. Does the project have environ- mental effects which will cause substantial adverse effect on human beings, either directly or indirectly? YES MAYBE NO NO•410 Before the Lead Agency can accept this application as complete, the applicant must consult the lists prepared pursuant to Section 65962.5 of the Government Code and submit a signed statement indicating whether the project and any alternatives are located on a site which is included on any such list, and shall specify any list. HAZARDOUS WASTE AND SUBSTANCES STATEMENT The development project and any alternatives proposed in this application are contained on the lists compiled pursuant to Section 65962.5 of the Government Code. Accordingly, the project applicant is required to submit a signed statement which contains the following information: 1. Name of applicant: Iwo 6efaiN WO 2. Address: 1 IMLW.#df & LAM ¥1LW r 14147 3. Phone Number: (4) ✓ t ' S-1S I 60 51 ,1,088 4. Address fooff- Site (street name and number if available, and ZIP code); '_�`7/ A LL i A fro t4-.0 Lr" 5. Local Agency (city/county): e £s7z; /4'7/5 6. Assessor's book, page, and parcel number: 7. Specify any list pursuant to Section 65962.5 of the Government Code: �0? CEOuad-e,?a/ 2GS�f 8. Regulatory identification number: i/ 9. Date of List: V /1,1 I 1 Z Date ,) / -7 ! J (Signature) For (Applicant) III NOTE • In the event that the project site and any alternatives are not listed on any list compiled pursuant to Section 65962.5 of the Government Code, then the applicant must certify that fact as provided below. I have consulted the lists compiled pursuant to Section 65962.5 of the Government Code and hereby _certify that the development project and any alternatives (proposed in this application are not contained on these lists. Date 5'3 For (Signature) (Applicant) CERTIFICATION: I hereby certify that the statements furnished above and in the attached exhibits present the data and information required for this initial evaluation to the bes--of my ability, and that the facts, statements, and information pr ted are true and correct to the best of my knowl ge and belie Date For (Signature) (Applicant)