This application is a public record. The City of La Pine will exempt from disclosure only information of a sensitive and confidential nature to the
extent required under the Oregon Public Records Law (ORS 192.410-192.505, as amended) and other applicable laws.
The undersigned Applicant (or authorized agent) hereby declares under penalty of perjury as follows: (a) all
information contained in this application is true, accurate, and complete; (b) the business subject to this
application is not prohibited by, and is in compliance with, all applicable federal, state, and/or local laws,
regulations, and/or ordinances; (c) Applicant has read, understands, and agrees to abide by City of La Pine
Ordinance No. 2014-02; and (d) if Applicant is an entity, the authorized agent has the requisite power and
authority to sign and submit this application on behalf of Applicant.
If Applicant is a foreign person or entity, or a non-resident of the State of Oregon, and no permanent
business location is proposed to be created in the City of La Pine, Applicant must (a) appoint a local person
acceptable to the City Manager to serve as an agent for accepting service of process, notice, and/or demand,
and (b) submit with this application such local person’s consent to acceptance of service of process, notice,
and/or demand.
Authorized Agent’s Signature (if Applicant is an
entity): __________________________________
By/Its:_____________________________
Property Owner’s Signature (or the authorized agent
of the property owner):
______ __
By/Its:_____________________________
Authorized Agent/Local Person’s Signature (if
applicable):
By signing above, the above signed person agrees to
serve as agent for the Applicant/business subject to
this application and will accept service of process,
notice, and/or demand on behalf of the
Applicant/business subject to this application.
Name and Address of Authorized Agent/Local Person
(if applicable):
Date Received:
Receipt No.:
Amount of Fee Paid:
Business License No.:
This application has been submitted to the City of La Pine. Please review the applicant’s data specific to
your department and
provide comment as appropriate. Please sign below, indicate approval or state why
you disapprove, and provide any additional
comments. If you require additional space for your comments,
please attach your comments by separate page to this application.
Deschutes County Health Department Signature: Date: Approve: Yes □ No □
Comments:
La Pine Community Development Department Signature: Date: Approve: Yes □ No □
Is Site Plan required? Yes □ No □; Is location appropriately zoned for this business use? Yes □ No □; Has
Site Plan been submitted and approved? Yes □ No □; Is conditional use permit required? Yes □ No □
Comments:
Deschutes County Sheriff’s Department Signature: Date: Approve: Yes □ No □
Comments:
La Pine Fire District Signature: Date: Approve: Yes □ No □
Comments:
La Pine Public Works Signature: Date: Approve: Yes □ No □
Comments:
La Pine City Manager Approval Signature: Date: Approve: Yes □ No □
Comments:
