424, Construct a new guest house, Application• •
RE EST FOR HEARING
CITY OF ROLLING HILLS
APPLICATION FOR: CONDITIONAL USE PERMIT
The Undersigned C)
Name9. `\
Qi J c4 CI kr . N4�RT13
.Street Address
is/are the owner(s) of
or is/are in lawful possession of
(2) haspermission of the owner
Legal description of property situated at
pA.s �vvc
Street Address
53c) Olol61
Telephone Number
1 ^J P_OLLII'Cz
Lot Tract
Describe in detail the nature of the proposed use and under what Section of the Zoning
Ordinance the use is permitted in the zone in which it is located with a conditional
use permit. -
C-t U C 5 T. I-1 . D U 5 C R. A S- Z Z. c
1 LI(o.0 I2 .fir'
Will the proposed use be compatible with the uses in the surrounding area, and if so,
why?
1:7(jr5 T I-101)5r- �JrLt� 1(3j2 VI UA - (7)
• 14 1)(a-A G. 1-1 rb (C.? P Q r) P C' c T I c_
Q 1 au 5 A c c. s'oac `3 r.,a ! Lr i N r, .S
Will the grant of this conditional use permit be consistent with and in furtherance
of the public health safety and general welfare?
TW != G, t 1 [%5 T I -I o () ' C c t) (L I 93 Cr (Q N 51p U c -Fizz-- 0
\A1—►M Los n(oC-lGL-C-5 CooN-Q f LQc�-�- � r --e,)
FILING FEE
A filing fee ALAIWWZigligi4od must accompany the application. Make check payable to:
THE CITY OF ROLLING HILLS
• o
OWNER'S DECLARATION
I, (We), declare under penalty of perjury that the foregoing is true and correct.
Executed at I (Z 0.. p
this 2 r
day of M
5 Q U A1 L 9.1 o c-, ..
iJ or4b
Address
QoLLIFJC-1 t4ILLS c)0274.
California,
19 3c
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
ffixed, or before another officer of that State authorizedby itslaws to take . ,.
acknowledgments, that he (it) owns the property described herein, and that the
information in the accompanying this application is true to thebest of his (its)
knowledge and belief. Attach appropriate acknowledgment here.
FORMS ISSUED TO:
NAME
ORGANIZATION
JOB. ADDRESS
DATE -
DECISION OF PLANNING COMMISSION
FILED
FEE $
RECEIPT NO'
•
•
19 _.
The action of the Planning Commission will be final unless within twenty (20) days
following the notice to the applicant of the decision, an appeal in writing is filed
with the City Clerk by:
A. The applicant;
B. Any person who protested, either orally or in writing, as a matter of record,
prior to the final vote of the Planning Commission on the matter and who, in
addition, received or was entitled to receive the written notice specified
in subdivision 2 of subsection A of Section 17.40.060; or
C. The City Council, upon the affirmative vote of three members of the Council.
In order to obtain a building permit, it will be necessary for the applicant to sign
a copy of the findings that they understand and accept the conditons of approval.
•
i
REOUEST FOR HEARING
FOR SITE PLAN REVIEW
CITY OF ROLLING HILLS
The
undd ersigned DO /t2
Name
Street Address
530-0 4; 4;/
Telephone No.
(1) is/are the owner(s) or is/are lawful possession of
has permission of the owner
Legal description of property situated at
Street Address
NATURE OF PROPOSED PROJECT
//.-3
Lot
/V/GZ
Tract
Describe in detail the nature of the proposed project, including what
aspects of the project require a Site Plan Review.
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 to the below criteria:
A. Is the project compatible with the General Plan, the zoning
ordinance and surrounding uses? Explain how it compares to sizes,
set -backs and other characteristics of neighboring houses.
B. 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.
67(I( i /10(,)S /5-477
5
• •
C. 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 or
re -direct drainage flow unless into an existing drainage courses.
Explain the nature and extent of the impact of grading and proposed
minimization measures.
,Q rJ
D. 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.
/ O / // 4//7
747
E. Does the site development plan substantially 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.
5 -- /,7- / S /`` �'�.�-/ %�'C�'.��rz-.��
/`�,4 X 7- ,-,7 /i w 5
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.
l % / S i
6
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 and landscaping and other on -site parking
or storage areas. ,:2
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.
I hereby certify that the statements furnished above, and in attached
exhibits, present the data and information required for the site plan
review criteria eevaluation to be the best of my ability; and, that
the facts, statements and other information presented are true and
correct to the best of my knowledge and belief.
DATE: ? / 9 e%I
A4ev/24_Z-Ar
SIGNATURE
FOR r>---,
APPLICANT
7
lb i
• *
COMPUTATION OF LOT COVERAGE
CITY OF ROLLING HILLS
LOT COVERAGE (Ordinance No. 188)
Main buildings, accessory buildings, structures, tennis courts, swimming pools,
service yards (enclosed or unenclosed), stables, or an area of not less than 200 square
feet for the construction of a stable (with vehicle access thereto) shall not cover
more than twenty (20%) percent of the net lot area; provided further that in addition
to the above described improvements, the areas included within driveways, parking
space, walks, patios, decks and asphalt or concrete paving of any kind excepting
roads maintained by the Rolling Hills. Community Association, shall not cover more
than thirty-five (35%) percent of the net lot area.
For the purposes of this Section 'net a: a' shall exclude all perimeter easements
a maximum of ten feet and that portion of the lot or parcel of land which is used
for roadway purposes, and shall also exclude any private drive ordriveway which pro-
vides ingress and egress to any other lot or parcel of land, and access strip portion
of any flag lot.
'BUI?.DING AREA -CALCULATIONS
NET -LOT AREA
RESIDENCE - sq. ft.-
GARAGE -- sq. ft.
SWIMMING POOL .-sq. ft.
sq. ft.
sq. ft.
TOTAL SQUARE FEET ;l} 0
% COVERED (MAY NOT EXCEED 20% OF NET LOT AREA) 1
DRIVEWAY 3 t IA sq. ft.
PAVED WALKS AND PATIO AREA t 9 1 sq. ft.
POOL DECKING 1� 8 sq. ft.
STABLE
kcal, te
TOTAL SQUARE FEET 1 1 9 ¢
TOTAL COVERAGE (MAY NOT EXCEED 35% OF NET LOT AREA) Ci. 2.3 %
411
CHECKLIST FOR PLAN SUBMITL 411
rs
The following information must be included on any plan submitted for checking to the
Rolling Hills Planning Commission for:
a) Conditional Use Permit
b) Variance (including grading requirements)
Show the following:
Name and address of resident and name and address of architect and
Civil Engineer.
2. Vicinity map, scale 1:200 feet.
Requested improvements should be -dimensioned to property line and
residences of all contiguous properties.
Easements should be shown and dimensioned on subject property and
all contiguous properties, on property line nearest improvement.
3. North arrow and scale of plans.
4. Existing contours of the entire lot.
5. Square footage of.pads in accordance with City Ordinance 188.
6., Computation of lot coverage in -accordance with City Ordinance.188.--
7. All slopes shall not be steeper in slope than two horizontal to one
vertical, or exceed a vertical height of 30 feet. All slopes shall
marked with grade. (Ordinance 153) _. -
8. All cut and fill slopes must be shaded. (Ordinance 153)
9. Show all retaining walls and sections through walls., height and
elevations. . -:.Show height for all buildings.
10. Show proposed drainage pattern of graded areas.
11. The defined area(s) for which the Variance or Conditional Use Permit
is requested.
be
12. Show outline of residence and any additional structures. All structures
must be physically measured and square footage of each structure must
be shown on drawing. A note must be on the drawing certifying to those
measurements.
13. Show a graded area of not less than 200 square feet for the construction
of a stable and a graded road of not more than 25% grade for vehicular
access to the stable site. (Ordinance 188)
14. Sections should be shown through highest slope and through other areas
where ground is steep, and as many additional sections as necessary to
clearly delineate land contours with existing ground.
,35. A current survey and grading plan, showing all structures on the property,
with their distance from property lines delineated, will be required in
applications where the requested change is close to easements, close to
other properties, and/or where there is to be significant grading on
the property.
•
16. Distances from the centerline of.all existing and proposed streets
adjacent to the subject property.
•
I. (We, declare
and correct.
Executed at
this -7 r
OWNER'S DECLARATION
under penalty of perjury that the
7z7
day of
foregoing is true
, California,
19
5- C�
s)L ' 9i1 Z71
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 acknowledgments, 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.
FORMS ISSUED TO:
NAME
ORGANIZATION
JOB ADDRESS
H.N.M.
FILED
FEE
RECEIPT NO.
BY:
19
8
OWNER'S ACKNOWLEDGMENT
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 for property development is to obtain
City approvals first.
I, (We), the undersigned, acknowledge that the above statement
has been fully read and itsadmonition is completely understood.
Executed at , 1%L% J � , California
this / day of 5j4.!.s�,/=2 , 199C7 .
By: ldY/-,t-40�/
Address ji
By:
• • i •
CITY OF ROLLING HILLS
ZONING CASE
CERTIFIED PROPERTY OWNERS' LIST
AFFIDAVIT
STATE OF CALIFORNIA)ss.
COUNTY OF LOS ANGELES)
I; /-! VllJ (3 Thn/ , 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
�1Gt..D VEF215s L� 57';, ' , California, thin
Z �`Q day of / „A-Rct--f.. - . • -.., • 19 90.
Conditional Use Permit
0 Variance
0 Zone Change
Cm OF ROLLING HILLS
CONDITIONAL USE PERMIT
•
CONDITIONAL USE PERMIT,
Certain uses of property are permitted in the City only upon approval of a Conditional
Use Permit. Such uses are set forth in Sections 17.16.010 and 17.20.010 of the Municipal
Code.
APPLICATION AND RE9UFST FOR HEARING
In order to obtain a conditional use permit, a property owner or his or her agent must
submit an application and request a hearing before the Planning Commission. To do so, the
applicant should complete the requirements enumerated herein, assemble the necessary appli
cation documents and call to make an appointment at (213) 377-1521. Making an appointment
will assure that someone is available to explain the necessary procedures and review the
case material for completeness and accuracy.
PLAN SUBMITTAL INFORMATION
Complete and submit for each application:
1. "Request.fQr Rearing" Application. Fifteen copies of plan MUST•acedmpany-applicatia
2. Owner's Declaration t 'E,.•r ° �'-
3. Plan submittal using the 'Checklist" as guide. Each.plan must have computation of
lot coverage printed on the plot plan.
4. Ownership List: Prepare ancomplete list of names and mailing addresses of all property
owners of'each parcel, within or. partially within a 1,000 foot radius of the exterior
boundaries of the property under consideration, including the owner of the subject
property. Assign a number to each name on the list. This information must be. as it-
_ appears -on the latest available assessment -roll of the Los Angeles County Assessor.
-This list shall be certified- to_ be true and correct (complete Certified Property
Owner's Affidavit). An inaccurate or incomplete list is.cause for removal of the
case from the agenda or to require a rehearing of the case.
Type Self -Adhesive Mailing Labels: In addition to the Ownership List required, submit
one complete set of typed self-adhesive mailing labels for all property owners listed
on the Ownership List.
S. Certified Property Owners List Affidavit
6. _Filing -fee - Resolution #494 attached
REGULAR MEETINGS
Once an application has been accepted as complete by the City, a hearing will be set before
the Planning Commission. Applications are considered at the regular meetings of the Plan-
ning Commission, which are held the third Tuesday of each month. Applications must be
submitted to the Planning Commission Secretary no later than•the last Monday of the month
immediately preceding the regular greeting at, which the matter shall be considered. Provide
sufficient time in your plansgto attend at least two meetings to allow the Planning Com-
mission to study the facts°presented and to make•'h;;field trip review of the physical
conditions. The applicant or a representative must appear at the meeting.
AUTHORITY•AND RESPONSIBILITY.
In reviewing,:a raquest,Rth Panning Commission must consider the following:
1. The Planning Commission shall consider all matters presented to it fairly and impar-
tially, recognizing the rights of the applicant as well as its obligation to enforce
all zoning ordinances and resolutions adopted by the City Council of the City of
Rolling Hills.
2. The development and use of all land within the City of Rolling Hills should be directe4
to the continuation of the existing rural open areas surrounding the existing residence:
in the City, and each new improvement or use of land should be carefully examined to
determine what effect the proposed improvement or use of land will have on the terrain,
trees and natural flora in the City.
3. The granting of conditional use permits shall be carefully scrutinized to protect
bridle trails, and provide the proper spacing of residences and accessory building so
as to present overconstruction of the lot .or parcel to be improved.
•
(rev'd 19e1*
• • •
APPENDIX B
ENVIRONMENTAL INFORMATION AND CHECKLIST FORM
(Initial Study)
Date Submitted: No.
GENERAL INFORMATION
1. Name •and address of developer or project sponsor:
0 00 c,-3OR.�c.�
5 IQ ) 1 , H 4
2. Address of project: \ S 4-f3 (W L
Assessor's Block and Lot Number •7 5i G 9 - 1 O - 1 u
3. Name, address, and telephone number of person to be contacted
concerning this project:I O W-, •1"1 -5--t-1 A i T (ca nQ Tlet A4)
R. a 611 AE.E al G eda.P. 3 Q 1- Ta d o P I . P , \LJ ,
2t3)3i5--"2- 55
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: LeA me,
Cl�t��L'i 13iJCi -4- 5fk1-t.=TY
5. Existing zoning district: r2.14 ', - Z
6. Proposed use of site (Project for which this form is filed):
Cat?ESP 14 1,s
PROJECT DESCRIPTION
7. Site size:
8. Square footage:
'3®SG- Iic..
800
9. Number of floors of construction:
' ' - ' MLI19-11A•
•
•
• .
10. Amount of off-street parking provided:
11. (Attach plans.)
12. Proposed scheduling: N ,l\,
13. Associated projects: NI , i\
14. Anticipated incremental development: N.A.
15. If residential, indicate the number of units, schedule of unit
sizes, range of sale prices or rents, and type of household size
expected: %i , 4\ 1
16. If commercial, indicate the type, whether neighborhood, city
or regionally oriented, square footage of sales area, and loading
facilities: `, A ,
17. If industrial, indicate type, estimated employment per shift,
and loading facilities:
18. If institutional, indicate the major, function, estimated
employment per shift, estimated occupancy, loading facilities,
and community benefits to be derived from the project:
' • • , MLW9-1 k I 4
19. If the project involves a variance, conditional use or
rezoning application, state this and indicate clearly why the
application is required: Q, C . 0 , 2. IDS r e g u 1'red
ENVIRONMENTAL SETTING
20. On a separate page, 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.
21. On a separate page, 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, and
scale of development (height, frontage, set -back, rear yard,
etc.). Attach photographs of the vicinity.
ENVIRONMENTAL IMPACTS
(Explanations of all "yes" and "maybe" answers are required
on attached sheets.)
22. Earth. Will the proposal result in:
a. Unstable earth conditions or in
changes in geologic substructures?
b. Disruptions, displacements, com-
paction or overcovering of the soil?
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?
YES MAYBE NO
MLW9-19A* . '•
•
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?
23. Air. Will the proposal result in:
a. Substantial air emissions or
deterioration of ambient air quality?
b. The creation of objectionable
odors?
c. Alteration of air movement,
moisture or temperature, or any
change in climate, either locally
or regionally?
24. Water. Will the proposal result in:
a. Changes in currents, or the course
or direction of water movements, 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 of
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 addi-
tions or withdrawals, or through
interception of an aquifer by cuts
or excavations?
YES MAYBE NO
x
X
M4L,19-2Ok 0 0
• •
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?
j. Significant changes in the
temperature, flow, or chemical
content of surface thermal springs?
25. 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
of plants?
b. A 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 replenish-
ment of existing species?
d. Reduction in acreage of any
agricultural crop?
26. 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 microfauna)?
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
movement of animals?
d. Deterioration to existing fish
or wildlife habitat?
27. Noise. Will the proposal result in:
a. Increases in existing noise
levels?
YES MAYBE
NO
$LW9-21A* • •
• •
b. Exposure of people to severe
noise levels?
28. Light and Glare. Will the
proposal produce new light or
glare?
29. Land Use. Will the proposal
result in a substantial alter-
ation of the present or planned
land use of an area?
30. 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?
31. Risk of Upset. Will the proposal
involve:
a. A risk of an explosion or
the release of hazardous substances
(including, but not limited to, oil,
pesticides, chemicals or radiation)
in the event of an accident or up-
set conditions?
b. Possible interference with an
emergency response plan or an emer-
gency evacuation plan?
32. Population. Will the proposal
alter the location, distribution,
density,'or growth rate of the
human population of an area?
33. Housinq. Will the proposal af-
fect existing housing, or create
a demand for additional housing?
34. Transportation/Circulation. Will
the proposal result in:
a. Generation of substantial addi-
tional vehicular movement?
b. Effects on existing parking
facilities, or demand for new
parking?
c. Substantial impact upon
existing transportation systems?
YES MAYPE NO
MLW9-22A
• ••
d. %iterations to present
patterns of circulation or move-
ment of people and/or goods?
e. Alterations to waterborne,
rail or air traffic?
f. Increase in traffic hazards
to motor vehicles, bicyclists or
pedestrians?
35. 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?
e. Maintenance of public
facilities, including roads?
f. Other governmental services?
36. Energy. Will the proposal result in:
a. Use •of substantial amounts of
fuel or energy?
b. Substantial increase in demand
upon existing sources of energy,
or require the development of new
sources of energy?
37. 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?
f. Solid waste and disposal?
-7-
YES MAYBE
NO
z
• •• '•
�i,�19-Z31►*
• • •
38. Human Health. Will the.proposal
result in:
a. Creation of any health hazard
or potential health hazard
(excluding mental health)?
b. Exposure of people to poten-
tial health hazards?
39. Aesthetics. Will the proposal
result in the obstruction of any
scenic vista or view open to the
public, or will the proposal re-
sult in the creation of an aesthet-
ically offensive site open to
public view?
40. Recreation. Will the proposal
result in an impact upon the
quality or quantity of existing
recreational opportunities?
41. 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 aesthet-
ic effects to a prehistoric or
historic building, structure,
or object?
c. Does the proposal have the
potential 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?
42. Mandatory Findings of Significance.
a. Does the project have the
potential 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
-8-
YES MAYBE NO
MLW9.24A*
• •
the range of a rare or endangered
plant or animal or eliminate impor-
tant examples of the major periods
of California history or prehistory?
b. Does the project have the
potential 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, defin-
itive period of time while long-term
impacts will endure well into the
future.)
YES MAYBE- NO
c. Does the project have impacts
which are individually limited, but
cumulatively considerable? (A project
may impact on two or more separate re-
sources where the impact on each resource
is relatively small, but where the ef-
fect of the total of those impacts on
the environment is significant.)
d. Does the project have environ-
mental effects which will cause sub-
stantial adverse effect on human be-
ings, either directly or indirectly?
CERTIFICATION: I hereby certify that the statements furnished
above and in the attached exhibits present the data and infor-
mation required for this initial evaluation to the best of my
ability, and that the facts, statements, and information
presented are true and correct to the best of my knowledge and
belief.
Date ill, 11 14)1 o
1:1
For pN ` ibl�.C.�
(Applicant)