Page 12 - skylineranch122016

Please complete and return to:
Department of Regional Planning
320 West Temple Street, 13th Floor
Los Angeles, California 90012

AFFIDAVIT OF ACCEPTANCE

STATE OF CALIFORNIA }ss
COUNTY OF LOS ANGELES

REGARDING: PROJECT NO. 04-075-(5)
AMENDMENT TO VESTING TENTATIVE TRACT MAP NO. 060922
HIGHWAY REALIGNMENT NO. RPPL2016004512
SKYLINE RANCH ROAD, SAND CANYON ZONED DISTRICT
APN(S): SEE ATTACHED

I/We the undersigned state:

I am/We are the permittee of the above-mentioned permits and/or owner of the real property described above on Exhibit
"A', attached hereto. I am/We are aware of, and accept, all the stated Conditions of Approval for the above-mentioned
project.

I/We acknowledge that I/We and my/our successors in interest may be required to reimburse the Department of Regional
Planning for any additional enforcement efforts necessary to bring the subject property into compliance.

Executed this day of ,20

I/We declare under the penalty of perjury that the foregoing is true and correct.

Applicant's Name: ________________ _
Complete both Applicant and Owner
sections, even if the same.
Address:
-----------------
Signatures must be acknowledged by a City, State, Zip: _______________ _
Notary Public. Affix seal or appropriate
acknowledgements. Signature:
----------------

Owner's Name:
----------------
Address:
----------------
City, State, Zip:
----------------
Signature:
----------------

CC.03/03/15