HomeMy WebLinkAboutPA 2018-36 - Exhibit C CofAApplicant’s Initials: _____ Page 1 of 12
CONDITIONS OF APPROVAL
RESOLUTION: 2020-XX & 2028-XX
PROJECT: PA 2018-36/DA 2018-04/CUP 2018-08
PROJECT NAME: Veterans Organic Solutions
PROJECT LOCATION: 31875 Corydon Suite 120 and 31881 Corydon Suite
160 APN: 370-051-008 AND 031
APPROVAL DATE:
EFFECTIVE DATE:
EXPIRATION DATE:
General Conditions
1. Planning Application No. 2018-36 (Development Agreement No. 2018-04 and Conditional
Use Permit No. 2018-08) proposes to establish an approximately 8,099 proposed and
uses consists of:
Office/Administrative: 541sf
Shipping/Receiving: 328sf
Dispensary: 1,506sf
Other (Please Describe)
Manufacturing Rooms: 1, 793sf
Distribution: 570sf
Electrical/ Storage Closets/ Hallways/ Restrooms/ Entry Room: 3,066sf.
Secure Storage.
o Retail: 63sf
o Manufacturing: 134sf
o Distribution: 98sf
The Project is generally located at the northeast corner of the intersection Cereal and
Corydon and more specifically referred to as 31875 Corydon Suite 120 and 31881
Corydon Suite 160 (APN:370-051-008 and 031). The subject site is zoned M1.
2. Conditional Use Permit No. 2018-08 shall be limited to the floor plan prepared by the
applicant and included in the staff report. In the event the applicant proposes to modify
the floor plan, the modification shall be subject to review by the Community Development
Director. The Community Development Director may approve the modification or refer the
matter to the Planning Commission if judged to be substantial.
3. The applicant shall defend (with counsel acceptable to the City), indemnify, and hold
harmless the City, its Officials, Officers, Employees, Agents, and its Consultants
(Indemnitees) from any claim, action, or proceeding against the Indemnitees to attack, set
aside, void, or annul an approval of the City, its advisory agencies, appeal boards, or
legislative body concerning approval, implementation and construction of CUP 2018-08
which action is bought within the time period provided f or in California Government Code
Sections 65009 and/or 66499.37, and Public Resources Code Section 21167, including
the approval, extension or modification of CUP 2018-08 or any of the proceedings, acts
or determinations taken, done, or made prior to the decision, or to determine the
reasonableness, legality or validity of any condition attached thereto. The Applicant's
indemnification is intended to include, but not be limited to, damages, fees and/or costs
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awarded against or incurred by Indemnitees and costs of suit, claim or litigation, including
without limitation attorneys' fees, penalties and other costs, liabilities and expenses
incurred by Indemnitees in connection with such proceeding. The City will promptly notify
the applicant of any such claim, action, or proceeding against the City. If the project is
challenged in court, the City and the applicant shall enter into formal defense and
indemnity agreement, consistent with this condition.
4. Within 30 days of Project approval and prior to issuance of any building permits, the
applicant shall sign and complete an “Acknowledgement of Conditions,” and shall return
the executed original to the Community Development Department for inclusion in the case
records.
5. Conditional Use Permit No. 2018-08 shall lapse and become void two years following the
date on which the Conditional Use Permit became effective, unless one of the following:
(1) prior to the expiration of two years, a building permit related to the conditional use
permit is issued and construction commenced and diligently pursued toward completion;
or (2) prior to the expiration of two years, the applicant has applied for and has been
granted an extension of the design review approval pursuant to subsections (B) and (C)
of LEMC Section 17.168.080. Subject to the provisions of LEMC Section 17.168.110, a
conditional use permit granted pursuant to the provisions of this section shall run with the
land and shall continue to be valid upon a change of ownership of the site or structure,
which was the subject of the Conditional Use Permit application.
6. The Conditional Use Permit granted herein shall run with the land and shall continue to be
valid upon a change of ownership of the site or structure which was the subject of this
approval. An application for modification, expansion or other change in a Conditional Use
Permit shall be reviewed according to the provisions of the LEMC, Title 17 in a similar
manner as a new application.
7. Suspension of a license issued by the State of California, or by any of its departments or
divisions, shall immediately suspend the ability of a cannabis facility to operate within the
City, until the State of California, or its respective department or division, reinstates or
reissues the State license. Should the State of California, or any of its departments or
divisions, revoke or terminate the license of a cannabis facility, such revocation or
termination shall also revoke or terminate the ability of a cannabis facility to operate within
the City. This CUP will expire and be of no further force and effect if any state issued
license remains suspended for a period of 6 months. Documentation of three violations
during routine inspections or investigations of complaints shall result in the scheduling of
a hearing before the Planning Commission to consider revocation of the Conditional Use
Permit.
8. This business operator shall pay all sales, use, business and other applicable taxes, and
all license, registration, and other fees and permits required under federal, state and local
law. This business operator shall pay all sales, use, business and other applicable taxes,
and all license, registration, and other fees and permits required under federal, state and
local law. This business operator shall cooperate with the City with respect to any
reasonable request to audit the business' books and records for the purpose of verifying
compliance with State and Local regulations and this CUP, including but not limited to a
verification of the amount of taxes required to be paid during any period and the limitation
on gross sales receipts.
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9. The applicant shall pay all applicable City fees, including but not limited to: Development
Impact Fees (DIF), Fire Facilities Fees, and Traffic Infrastructure Fees (TIF) per LEMC
Section 16.74, Transportation Uniform Mitigation Fees (TUMF) per LEMC Section 16.83,
Area Drainage Fees per LEMC Section 16.72, MSHCP Fee per LEMC Section 16.85,
Capital Improvement Impact/Mitigation Fees, Stephens Kangaroo Habitat Fee (K-Rat) per
LEMC Section 19.04, and Plan Check fees, at the rate in effect at the time of payment.
Operational Standards
10. The uses authorized by this Conditional Use Permit must be conducted in accordance
with all applicable state and local laws, including, but not limited to compliance with the
most current versions of the provisions of the California Code of Regulations that regulate
the uses permitted hereby. Any violation thereof shall be a violation of the conditions of
this permit and may be cause for revocation of this permit.
11. The applicant shall at all times comply with Chapter 17.176 (Noise Ordinance) of the
LEMC. Prior to the issuance of a building permit, documentation demonstrating
compliance shall be provided.
12. The applicant shall at all times comply with Chapter 14.08 (Stormwater/Urban Runoff
Management and Discharge Control of the LEMC. Prior to the issuance of a building
permit, documentation demonstrating compliance shall be provided.
13. Odor control devices and techniques shall be incorporated to ensure that odors from
marijuana are not are not detected outside the property, anywhere on adjacent property
or public right-of-way, or within any other units located within the same building as the
cannabis facility. Building and mechanical permits must be obtained from the Building
Division prior to work commencing on any part of the odor control system.
14. Air quality control devices and techniques shall be incorporated to ensure that the ambient
external air quality is not impacted by the cannabis facility. Building and mechanical
permits must be obtained from the Building Division prior to work commencing on any part
of the air quality control system. Prior to the Building Division issuing a building permit
contact the South Coast Air Quality Management District (AQMD) located at: 21865
Copley Dr. Diamond Bar, CA 91765-4178, Tel: 909- 396-2000. A building permit shall not
issued until an Identification Number is provided by AQMD and any applicable permits
have been issued.
15. Applicant shall contact the Elsinore Valley Municipal Water District (the local water and
sewer purveyor) and submit an application and plans for project review. Applicant must
obtain approval of all plans prior to the issuance of a building permit and a letter of project
completion by the District prior to the issuance of a Certificate of Occupancy. Any
Cannabis facility shall meet the minimum requirements of the district and not discharge
any material into a sewer system without first obtaining approval.
16. No outdoor storage, cultivation, manufacturing or any other form of use of cannabis or
cannabis products, byproducts or waste are permitted at any time.
17. The sale, dispensing, or consumption of alcoholic beverages on or about the premises is
prohibited.
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18. The consumption of any cannabis or cannabis product in any form is prohibited from
occurring onsite.
19. The owner/operator shall prohibit loitering by persons outside the facility both on the
premises and within fifty feet (50') of the premises.
20. Persons under the age of twenty-one (21) years shall not be allowed on the premises of
this business. It shall be unlawful and a violation of this CUP for the owner/operator to
employ any person who is not at least twenty-one (21) years of age.
21. There shall be no loitering in or around the business.
22. The operator shall maintain free of litter all areas of the premises under which applicant
has control.
23. No cannabis or cannabis products, or graphics depicting cannabis or cannabis products,
shall be visible from the exterior of this property, or on any of the vehicles owned or used
as part of the cannabis business.
24. Cannabis liquid or solid waste must be made unusable and unrecognizable before leaving
a secured storage area and shall be disposed of at facility approved to receive such waste.
25. Extraction and post-processing winterization operations shall be conducted according to
the approved Registered Design Professional's technical report; approved Fire Protection
Plan; and the approved building construction plans. Any change in equipment, operation,
or hazard shall be submitted to the City for review and approval before the change taking
place.
26. The storage, use, and disposal of volatiles, solvents, or hazardous materials at this facility
shall be conducted according to the 2016 California Fire Code and the Riverside County
Environmental Health Department regulations.
27. All cannabis and cannabis products sold, distributed or manufactured shall be cultivated,
manufactured, and transported by licensed facilities that maintain operations in full
conformance with State and local regulations.
28. Cannabis Facility Site Restricted.
No cannabis permittee shall open their cultivation site to the public.
No cannabis permittee shall allow anyone on the cultivation site, except for managers,
staff, and other persons with a bona fide business or regulatory purpose for being
there, such as contractors, inspectors, and cannabis transporters.
A manager must be onsite at all times that, any other person, except for security
guards, is on the site.
While onsite, managers and staff of the cannabis cultivation permittee must wear their
identification badge at all times.
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Any person other than managers or staff who are on the cultivation site must sign in,
wear a visitor badge, and be escorted on the site by a manager at all times.
29. The use shall be conducted, at all times, in a manner that will allow the quiet enjoyment
of the surrounding neighborhood. The operator shall institute whatever security and
operational measures are necessary to comply with this requirement.
30. If operation of this use triggers concerns related to parking, noise, traffic, or other impacts,
at the discretion of the Community Development Director, this Conditional Use Permit may
be referred back to the Planning Commission for subsequent review at a Public Hearing.
If necessary, the Commission may modify or add conditions of approval to mitigate such
impacts, or may revoke said Conditional Use Permit.
Site Security Plans
31. Each cannabis facility shall have a security plan approved by the City prior to the issuance
of a Cannabis Business Permit. The security plan shall be a narrative and also an include
a detailed security plan delineating the physical location of the specific equipment. The
proposed security plan must include the following at a minimum:
Summary of the security plan, this shall be included in the project description, all other
elements shall be incorporated as a separate attachment, entitled security plan, to the
project description.
Security surveillance cameras. Security surveillance cameras and a video recording
system must be installed to monitor all doors into the buildings on the site, the parking
lot, loading areas, and all exterior sides of the property adjacent to the public rights of
way. The cameras and recording system must be of adequate quality, color rendition,
and resolution to allow the identification of any individual present on the site. The
recording system must be capable of exporting the recorded video in standard MPEG
formats to another common medium, such as a DVD or USB drive.
Security video recording and retention. Video from the security surveillance cameras
must be recording at all times (24 hours a day, seven days a week) and the recording
shall be maintained for at least 30 days. The video recordings shall be made available
to the City upon request.
Location of security cameras and the areas to be covered by the security cameras.
Location of audible interior and exterior alarms.
Location of exterior lighting.
Name and contact information of Security Company.
Entrances to all dispensing and cultivation areas will be locked and under control of
staff at all times.
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Name of security guard and proof that security guard is licensed by the California
Department of Consumer Affairs and whether security guard will be present at the
cannabis facility during all hours of operation.
If the security guard is to be armed, proof that security guard possesses a valid
Security Guard Card and Firearms Permit issued by the California Department of
Consumer Affairs.
Alarm system. Professionally and centrally-monitored fire, robbery, and burglar alarm
systems must be installed and maintained in good working condition. The alarm
system must include a private security company that is required to respond to every
alarm.
32. Any modifications to the approved security plan shall be reviewed and approved prior to
the modifications being implemented.
33. Site security plans requirements may change at the sole discretion of the City. Any
changes of requirements imposed by the City shall be complied at minimum during the
annual inspection process or sooner as required by the City.
34. In the event any discrepancies between local and state regulations exist, the more
restrictive requirements shall prevail.
Fire Protection Plan
35. Each cannabis facility shall have fire protection plan approved by the Fire Marshal prior to
the issuance of a Cannabis Business Permit. The fire protection plan shall be a narrative
and also include a detailed fire protection plan delineating the physical location of the
specific equipment. The proposed fire protection plan must include the following at a
minimum:
Summary of the fire protection plan, this shall be included in the project description, all
other elements shall be incorporated as a separate attachment, entitled security plan,
to the project description.
Occupancy Classification. The Use and Occupancy Classification of Marijuana
Business. Please identify the proposed use and occupancy classification of the
proposed use. Use and occupancy classifications may be found in Chapter 3 of the
California Building Code (CBC), and California Fire Code (CFC).
Hazard Communication. When storing or using any type of hazardous materials, CFC
Section 407 should be followed and the appropriate paperwork made accessible to
the fire code official. Additionally the CFC should be consulted. The CFC gives
responders the information of the hazardous chemicals that is on the property.
o Material Safety Data Sheets (MSDS) shall be on property and made easily
accessible.
o Containers and/or packages related to hazardous materials shall be properly
labeled and warning signage shall be properly displayed and easily visible.
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o All persons shall be trained on what to do in the event of an emergency involving
hazardous material on the property.
Fire protection plans shall refer to the location of all hazard communication information.
Interior Finishes. It is common in marijuana grow facilities to use a Visqueen® or
Mylar® type plastic/polyethylene or polyester sheeting to cover walls and ceilings. Any
use of plastic to enclose rooms or cover walls and/or ceilings must be installed in
accordance with building and fire code requirements. Interior finishes must comply
with flame spread ratings in accordance with Table 803.3 of the CFC. (Note: Hanging
plastic from ceilings or suspended overhead structures to create wall dividers is
typically NOT compliant with code provisions for a wall partition or interior finish.)
Exits and Exit Signage, Egress Security measures are often extreme in cannabis
facilities. The desire for security in no way overrides the minimum requirements for
exiting and egress. Common issues associated with exits and egresses are as follows:
Number of exits shall be in accordance with the CFC. Fire protection plan shall identify
o Means of egress cannot be concealed in any way.
o Exit doors and their function (these cannot be eliminated without prior approval).
o Where 2 or more exits are required, egress doors are required to swing in the
direction of egress travel.
o Where more than one exit is required, illuminated exit signs are to be provided that
must be readily visible from any direction of egress travel.
o Intermediary exit signs may also be required per Section 1013 of the CFC.
o H occupancies require specific considerations for exiting.
Locks and Key Box Where security and life safety objectives conflict, alternative
measures may be required or permitted by the City. SECURITY GATES – Due to the
increased security measures typically required, and the potential hazards associated
with marijuana facilities, the City is authorized to require that any security gate be
installed across a fire apparatus road first be approved before installation.
o KEY BOXES – Installation of a key box in an approved location, which will permit
timely access to the facility in the event of an emergency shall be identified.
o LOCKS – The installation of “approved” locks on any and all gates or similar
barriers, which will permit timely access to all areas of the facility’s property in the
event of an emergency. If the facility has electronic access controls, the City will
require an access code or electronic access card be provided.
o BOLTS, BARS, LOCKS & LATCHES – Egress doors are required to open easily
when exiting without the need for a key, without using extra effort and/or without
having special knowledge in order to operate the installed hardware. Door handles,
pulls, latches, locks and other operating devices should be free of tight grasping,
tight pinching or twisting of the wrist to operate. Slide bolts, security bars, dead
bolts, thumb latches and similar hardware items are prohibited from being installed
on emergency egress doors.
o ALTERNATIVE LOCKING DEVICES - Delayed egress locks and electromagnetic
locks are permitted for use in other occupancy types, and must be approved for
use by the City.
Fire suppression systems. Fire protection plan shall include all suppression systems
designed to meet the specific
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36. Fire prevention plan requirements may change at the sole discretion of the City. Any
changes of requirements imposed by the City shall be complied at minimum during the
annual inspection process or sooner as required by the City.
37. In the event any discrepancies between local and state regulations exist, the more
restrictive requirements shall prevail.
Closure Plan
38. Prior to the approval of a Cannabis Business Permit a separate document referred to as
a closure plan shall be reviewed and approved. At a minimum the closure plan shall
include
Remediation Plan. Describe how the cannabis facility will be remediated at end of use.
(Process of Removing Equipment, Chemicals, and other items/remnants).
A closure cost estimate. Closure costs include the expenses for ceasing operation of
the cannabis facility and safely closing the unit and cleaning up any contamination.
Post-closure care costs include long-term maintenance of the unit or facility,
monitoring, and record keeping during the required post-closure care period.
Owner/operators calculate cost estimates based on the cost of paying a third party to
perform the required closure and post-closure care activities as outlined in the facility's
remediation plan. Cost estimates must be adjusted annually throughout the
operational life of the facility to account for inflation.
39. Surety Bond. A surety bond from a surety company shall be submitted and maintained
through out the life of the cannabis business permit that all closure and post-closure plan
requirements will be fulfilled. If the owner/operator fails to meet the requirements specified
in the bond, the surety company is liable for the costs.
40. Closure plan requirements may change at the sole discretion of the City. Any changes of
requirements imposed by the City shall be complied at minimum during the annual
inspection process or sooner as required by the City.
41. In the event any discrepancies between local and state regulations exist, the more
restrictive requirements shall prevail.
Insurance
42. The owner/operator shall obtain and maintain at all times during the term of the permit
comprehensive general liability insurance and comprehensive automotive liability
insurance protecting the permittee in an amount of not less than one million dollars
($1,000,000.00) per occurrence, combined single limit, including bodily injury and property
damage and not less than one million dollars ($1,000,000.00) aggregate for each personal
injury liability, products-completed operations and each accident, issued by an insurance
provider admitted and authorized to do business in California and shall be rated at least
A-:viii in A.M. Best & Company's Insurance Guide. Proof of said insurance must be
provided to the Planning Division before the business commences operations. Any
changes to the insurance policy must be submitted to the Community Improvement
Division within 10 days of the date the change is effective.
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Signs
43. Street address shall be visible from the public street and/or shall be displayed on the
freestanding sign. If there is no freestanding sign, the street address may be displayed on
the fascia adjacent to the main entrance or on another prominent location. W hen the
property has alley access, address numerals shall be displayed in a prominent location
visible from the alley. Numerals shall be a minimum twelve (12) inches in height with not
less than three-fourth-inch stroke and shall contrast sharply with the background.
Identification of individual units shall be provided adjacent to the unit entrances. Letters or
numerals shall be four (4) inches in height with not less than one-fourth-inch stroke and
shall contrast sharply with the background.
44. The following signs in measurements of not less than eight by 10 inches shall be clearly
and legibly posted in a conspicuous location inside the cannabis site where they will be
visible to members and customers in the normal course of a transaction, stating:
Smoking, ingesting or consuming cannabis on this property or within 20 feet of the
cannabis facility is prohibited.
Drinking, ingesting or consuming alcohol on this property or within 20 feet of the
cannabis facility is prohibited.
That no person under the age of twenty-one (21) years of age is permitted to enter
upon the premises.
That loitering by persons outside the facility both on the premises and within fifty feet
(50') of the premises is prohibited.
Juveniles are prohibited from entering this property unless they are a qualified patient
or a primary caregiver and they are in the presence of their parent or legal guardian.”
Neither the City of Lake Elsinore, nor any other governmental agency, has tested or
inspected any cannabis product for pesticides, or other regulated contaminants,
distributed at this location.
45. Business identification signage shall be limited to that needed for identification only.
Business identification signage shall not include any references to marijuana or cannabis,
whether in words or symbols. All signs shall comply with the Municipal Code. No sign shall
be installed until the owner/operator or its designated contractor has obtained any permit
required from the City.
46. Signs on the cannabis facility building shall not obstruct the entrance or windows of the
distribution facility.
Records Retention/Reporting
47. The owner/operator of this cannabis facility shall maintain accurate books and records,
detailing all of the revenues and expenses of the business, and all of its assets and
liabilities. On no less than an annual basis, or at any time upon reasonable request of the
City, the owner/operator shall file a sworn statement detailing the number of sales by the
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medical marijuana business during the previous twelve month period (or shorter period
based upon the timing of the request), provided on a per-month basis. The statement shall
also include gross sales for each month, and all applicable taxes paid or due to be paid.
48. The owner/operator shall maintain a current register of the names and the contact
information (including the name, address, and telephone number) of anyone owning or
holding an interest in the medical marijuana business, and separately of all the officers,
managers, employees, agents and volunteers currently employed or otherwise engaged
by the cannabis facility. The register required by this condition shall be provided to the City
Manager upon a reasonable request.
49. The owner/operator shall maintain an inventory control and reporting system that
accurately documents the present location, amounts, and descriptions of all cannabis and
cannabis products for all stages of the production or manufacturing, laboratory testing and
distribution processes. Subject to any restrictions under the Health Insurance Portability
and Accountability Act (HIPPA), the owner/operator shall allow City officials to have
access to the business's books, records, accounts, together with any other data or
documents relevant to its permitted medical marijuana activities, for the purpose of
conducting an audit or examination. Books, records, accounts, and any and all relevant
data or documents will be produced no later than twenty-four (24) hours after receipt of
the City's request, unless otherwise stipulated by the City.
50. The owner/operator shall have in place a point-of-sale tracking system to track and report
on all aspects of the medical marijuana business including, but not limited to, such matters
as cannabis tracking, inventory data, and gross sales (by weight and by sale). The
owner/operator shall ensure that such information is compatible with the City's record-
keeping systems. The system must have the capability to produce historical transactional
data for review by the City Manager.
Construction Permitting
51. Any internal or external modifications to the building shall require a building permit.
52. No Certificate of Occupancy shall be issued without the issuance of a Cannabis Business
Permit and a City Business License.
53. The Applicant shall meet all applicable Building Codes in effect at the time, including but
not limited to: 2016 California Building Code, 2016 California Electrical Code, 2016
California Mechanical Code, 2016 California Plumbing Code, 2016 California Green
Building Standards Code, and 2016 California Energy Code (or the applicable adopted
California Building Code, California Electrical Code, California Mechanical Code,
California Plumbing Code, California Green Building Standards, and California Energy
Code, at the time of plan submittal or permit issuance) and California Code of Regulations,
also known as the California Building Standards Code, as amended by the City.
Requirements for accessibility to sites, facilities, buildings, and elements by individuals
with disability shall comply with Chapter 11 B of the 2016 California Building Code.
54. The conditions of approval and ordinance or code provisions of planning application PA-
18-06 shall be blueprinted on the face of the site plan as part of the plan check submittal
package.
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55. Plans shall be prepared by a California licensed Architect or Engineer Plans shall be wet
stamped and signed by the licensed Architect or Engineer prior to the issuance of building
permits.
56. The applicant/operator shall comply with all requirements of the Riverside County Fire
Department Lake Elsinore Office of the Fire Marshal.
57. Comply with the requirements of the 2016 California Fire Code and referenced standards
as amended by the City.
Conditional Use Permit Inspections
58. No person having responsibility for the operation of a cannabis business, shall impede,
obstruct, interfere with, or otherwise not to allow, the City to conduct an inspection, review
or copy records, recordings or other documents required to be maintained by a medical
marijuana business under this chapter or under state or local law. It is also unlawful for a
person to conceal, destroy, deface, damage, or falsifies any records, recordings or other
documents required to be maintained by a cannabis business under state or local law.
59. The City Manager or their designees may enter this business at any time during the hours
of operation without notice, and inspect the location of this business as well as any
recordings and records required to be maintained pursuant to LEMC or under applicable
provisions of State law. The City Manager or his or her designees may conduct inspections
at the site, as well as any recordings and records required to be maintained pursuant to
the Municipal Code or under applicable provisions of State law.
60. Quarterly Inspections will be conducted by the City to verify compliance with the approved
operation. The applicant will pay for the inspection according to the Additional Required
Inspections as adopted in the Fee Schedule. Code Enforcement officers, the Building
Official and/or the Fire Marshal may enter and inspect the location of this business
between the hours of 8:00 am and 5:00 pm Monday through Friday upon 24 hours
telephonic notice to the owner or operator, to ensure compliance with this CUP.
61. Annual Fire & Life Safety Inspections will be conducted by the Fire Station Crew for
emergency response pre-planning and site access familiarization. The applicant will pay
for the inspection according to the adopted Fee Schedule.
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I hereby state that I acknowledge receipt of the approved Conditions of Approval for the above
named project and do hereby agree to accept and abide by all Conditions of Approval as approved
by the City of Lake Elsinore City Council on ____________. I also acknowledge that all Conditions
shall be met as indicated.
Date:
Applicant’s Signature:
Print Name:
Address:
Phone Number: