Disclosure Pursuant to the
City of Pasadena Taxpayer Protection Act
Pasadena City Charter, Article XVII
I. Does the value of this application/project have the potential to exceed $25,000? Yes No (Applicant must mark one) II. Is the application being made on behalf of a government entity? Yes X No III. Is the application being made on behalf of a non-profit 501(c) organization? Yes X No If yes, please indicate the type of 501(c) organization: 501(c)(3) 501(c)(4) 501(c)(6) Applicant's name: _Baker Tilly US, LLP Date of Application: 3/20/2023 Owner's name: _Charles Droege Contact phone number:_513-861-5400 (for questions regarding this form)
Project Address: 4807 Innovate Lane, Madison, WI 53718_ Project Description: _management consulting
IV. Applicant and Property Owner must disclose all joint owners, trustees, directors, partners, officers and those with more than a 10% equity, participation or revenue interest in owner and/or project. If any of these are an organization/entity, include the name of the organization/entity and the first and last names of all parties of interest of that organization/entity. (List all parties below and use additional sheets as necessary, or provide all parties on an attachment) Please print legibly.
Have any additional sheets or an attachment been provided? Yes X No Names of Owner(s), Trustees, Directors, Partners, Names of Owners), Trustees, Directors, Partners, Those with more than a 10% equity, participation Officers of Owner/Project Officers of Owner/Project (continued) or revenue interest in Owner and/or project Vicki Hellenbrand
Charles Droege
I hereby certify that I am the owner or designated agent and that the statements and answers contained herein, and the information attached, are in all respects true, accurate and complete to the best of my knowledge and belief.
Signature of Owner or Designated Agent: Date: 3/20/2023 For Office Use Only
Type of Application: Variance (all types) Adjustment Permit Sign Exception Temporary Use Permit Expressive Use Permit Conditional Use Permit (excluding Master Plan) Master Plan Amendment Planned Development Assigned Planner: PLN#:
Attached Address: No Attached Address
Appealed: Yes No Appeal PLN# Application Withdrawn
Final Decision: Approved Denied Decision Date: Decision Maker:
(Name and Title, or Name of Commission/Committee)
Votes in favor (please print):
Revised July 2007