HomeMy WebLinkAboutCUP 215B; Van Voorhis/Shorter; Conditional Use Permit (CUP)+ City of (tarisbari
DISCLOSURE STATEMENT
APPUCANTS STATEMENT OF DISCLOSURE OF CERTAIN OWNERSHIP INTERESTS ON ALL APPLICATIONS
WHICH WILL REQUIRE DISCRETIONARY ACTION ON THE PART OF THE CITY COUNCIL OR ANY APPOINTED
BOARD, COMMISSION OR COMMITTEE.
(Please Print)
The following information must be disclosed:
1. Applicant
LJst the names and addresses of all persons having a financial interest in the application.
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2. Owner
List the names and addresses of all persons having any ownership interest in the property involved.
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3. If any person identified pursuant to (1) or (2) above is a corporation or partnership, list the names an
addresses of all individuals owning more than 10% of the shares in the corporation or owning any partnersh;
interest in the partnership.
4. If any person identified pursuant to (1) or (2) above is a non-profit organization or a trust, list the names anc
addresses of any person serving as officer or director of the non-profit organization or as trustee or beneficiar
of the trust.
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Disclosure Statement • Page 2
5. Have you had more than $250 worth of business transacted with any member of City staff, Scares
Commissions, Committees and Council within the past twelve months?
Yes No X If yes, please indicate person(s)
Person is defined as: 'Any individual, firm, copartnership, joint venture, association, social club, fraternal
organization, corporation, estate, trust, receiver, syndicate, this and any other county, city and county, city
municipality, district or other political subdivision, or any other group or combination acting as a unit.'
(NOTE: Attach additional pages as necessary.)
4L
Signature of Owner/date Signature of applicant/date
Print or type name of owner Print or type name of applicant