LAND USE APPLICATION
APPLICANT INFORMATION
Proposed change:
__________________________________________________________________________
__________________________________________________________________________
NAME OF APPLICANT: _______________________________________________________
NLast ame First Name
Mailing Address: _____________________ City: ______________ St _____ Zip ________
Applicant is: Ŀ Legal Owner Ŀ Agent
Phone Number of Applicant:
Work _________________ Home _____________________
Name of Contact Person, (if other than applicant) _________________________________
Mailing Address _________________ City: _________ St __________ Zip ________
Phone Number of Contact Person: work _____________ Home ____________________
Site Address: ______________________________________________________________
Legal Description T ___ R _____ Section __________ Tax Lot(s) ____________________
Present use of property: _____________________________________________________
Method of Sewage Disposal: __________________________________________________
Water Supply: _____________________________________________________________
Ŀ Required Attachments (see attached listing)
I hereby certify the statements contained
herein, along with the evidence submitted, are in all
respects true and correct to the best of my knowledge.
_________________________________ _____________________________________
Property Owner’s Signature Applicant’s Signature
Date: ___________________________ Date: ________________________________
The
Applicant’s Statement of Disclosure of
Interest
must be completed and included with any
application for Comprehensive Plan, Zoning Map Amendments, Variances, Conditional Use Permits, Partitions,
Subdivisions, Planned Unit Developments and all Appeals.
File No: __________________
Fee: $________Receipt No: _______
Staff: ____________________
City of Happy Valley
16000 SE Misty Drive
Happy Valley, Oregon 97086
happyvalleyor.gov
Phone: 503-783-3800 Fax: 503-658-5174
Date Rec'd: ________________
Please mark the applicable application type
Accessory Dwelling Unit (ADU) Application
Comprehensive Plan/Zone Change Application
Conditional Use
Design Review - Minor
Design Review - Major
Flood Management Overlay Zone
Habitat Conservation Area Map Verification - Basic
Habitat Conservation Area Map Verification - Detailed
Land Partition
Land Development Time Extension
Master Plan
Model Home
Natural Resource Overlay Zone
Planned Unit Development
Property Line Adjustment
Steep Slope Development Overlay Zone
Street Vacation
Subdivision
Temporary Use
Variance
Other
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APPLICANT’S STATEMENT OF DISCLOSURE OF CERTAIN
OWNERSHIP INTERESTS FOR LAND USE APPLICATION,
AMENDMENTS AND PERMITS
The City of Happy Valley’s Land Development Code requires that the following
information must be disclosed on any application for comprehensive plan map
amendments/zone changes, variances, conditional use permits, partitions, subdivisions,
planned unit developments, master plans and for appeals.
A. List the names of all persons having a financial interest in the application:
_________________________ ___________________________
_________________________ ___________________________
List the names of all persons having any ownership interest in the property
involved:
_________________________ _____________________________
_________________________ _____________________________
B. If any persons identified pursuant to (A) above is a corporation or a partnership,
list the names of all individuals owning more than 10% of the shares in the
corporation or owning any partnership interest in the partnership.
_________________________ __________________________
_________________________ __________________________
C. If any person identified pursuant to (A) above is a non-profit organization or
trust, list the names of any person serving as director of the non-profit
organization or as a trustee or beneficiary or trustor of the trust.
_________________________ ___________________________
__________________________ ___________________________
NOTE: The definition section of the Land Development Code defines “Person” as “Any individual, firm,
co-partnership, joint venture, association, syndicate, this and any other country, City and County,
municipality, district or other political subdivision or any other group or combination acting as a unit.
Applicant(s) hereby authorize the city staff, planning commission or city council members access and
entrance to the subject site for the purposes of information gathering prior to the public hearing.
Ŀ YES Ŀ NO
_________________________________ ___________________________________
Signature of Applicant Date
S:\ECONOMIC AND COMMUNITY DEVELOPMENT\Administra
tion\Planning Forms\Applications\Updated New Forms grouped in
packets\Conditional Use\Statment of Disclosure Form.doc
Revised 2-25-2016
IF THERE IS MORE THAN ONE OWNER LISTED IN ANY OF THE ABOVE AREAS,
PLEASE ATTACH ADDITIONAL FORMS WITH EACH OWNER’S SIGNATURE.
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