Form Date: 8/9/07 Page 1 of 2
CITY OF VISALIA
Disclosure Development Project
INCOMPLETE OR LATE SUBMISSION OF DISCLOSURE STATEMENT COULD RESULT IN CONTINUANCE OR DELAY OF YOUR PROJECT.
SITE:
Address or APN(s): ___________ ______________________________________________________________________ Short Title or Name of proposed project: _________________________________________________________________ Summary description of the proposed project: _____________________________________________________________ __________________________________________________________________________________________________ PROPERTY OWNER(S):
If more than two owners, please provide information and signature(s) on a separate sheet.
Name (print) _____________________________________ Name (print) ______________________________________ Mailing Address _________________________________ Mailing Address ____ _______________________________ _______________________________________________ _________________________________________________ Phone _________________________________________ Phone ___________________________________________ Statement: I/We declare under penalty of perjury that I am /we are the legal owner(s) of the property involved in this application. I/We authorize the person named in this a pplication as the Project Main Contact to act as my/our representative with City Staff regarding the processing of this application.
_______________________ ____________________________________________ D a t e P r o p e r t y O w n e r S i g n a t u r e ____________________________________________
Print Name & Title
_______________________ ____________________________________________ D a t e P r o p e r t y O w n e r S i g n a t u r e ____________________________________________
Print Name & Title
OTHER INVOLVED PARTIES:
Fill in all that apply.
It is planned that the property will be sold to ______________________________________________________________ (Write “none” if property owner(s) do not plan to sell property.) Developer/Builder __________________________________________________________________________________ Mailing Address ____________________________________________________________________________________ Phone _____________________ Fax _____________________
Form Date: 8/9/07 Page 2 of 2
NAMES OF PRINCIPALS, PARTNERS, AND/OR TRUSTEES:
List the names of all principals, partners, and/or trust ees where any property owner and/or developer/builder are a partnership or trust. For corporations provide names of officers, directors a nd all stockholders owning more than 10% equity interest in corporation:
NOTICE:
If the above information regardi ng ownership and interest in this pr operty changes before the project goes before City Council or Planning Commission, it is the responsibilit y of such parties to notify the City of Visalia of this change(s).