HomeMy WebLinkAboutCCH PETITION FOR GREGORY VLASEK (PL-CCH-2022-002) PETITION FOR STANDING IN A CONTESTED CASE HEARING
(Page 1 of 2)
NAME: C7O) Lf V LA S Er-
ADDRESS:
KADDRESS: 17 4o gAtiTA �MEz JAY
Sh �AAMChJTDF CA 25 £? l Ia
PHONE NO.: 22
APPLICANT/
DOCKET NO.: P1,- S PP 0,07,4 - 000011
A. Is your interest in this matter clearly distinguishable from that of the general public?
Yes No
If the answer is "yes", please explain:
I AN 7'NE ewMa , OF AN A D,3AGEtJT PROPIP-liZ..T 4 AT
q 4, !d 5.5 Crf&mE� R-b, ACRaSS 11+E s`tL�T r-Rom S11->r.
If the answer is "no", please explain how the proposed action will nevertheless cause you
actual or threatened injury:
B. Are you a government agency whose jurisdiction includes the land involved in the
subject request?
Yes No
If the answer is "yes", please explain the nature of the agency's jurisdiction:
C. Do you lawfully reside on or have some property interest in the land involved in the
subject request?
Yes No_
If the answer is "yes", please explain:
Appendix A
PETITION FOR STANDING IN A CONTESTED CASE HEARING
(Page 2 of 2)
D. Are you a person or persons descended from native Hawaiians who inhabited the
Hawaiian Islands prior to 1778, who practiced those rights which were customarily and
traditionally exercised for subsistence, cultural, or religious purposes?
Yes X No
If the answer is "yes", please submit any genealogical evidence and historical evidence
showing the exercise of those rights to support your statement:
AcrH -rtA� .d Tks2 L L3 nt2W �n�1 0 W 1 LH M F2EDP G-I Sr ILEEL
RAjSED HANM) Pao&Z iQ 33 iN "NOW LJW 15-64 OF '"el-W-L CARLd iNo N
1 N IS A A L.a A(,IT A-"4 Lt-rVe OF- N b,A A K A t W X141 G ga5k j PSD nj
IN HOUDt_uu.r WHo LJAli 1OD`10 NArige- HAVAIIpM T
PUJ2�1-►�S1=ice Wt �( WDob V J A��Jh �tf .a'T A& i5 ) 1N 2017,
AND PUkj TV ae:D a E VhQ2_, !N 2-D23. S&G�_f�+�i+t4�inlCL 7�
L-PrOb Mu tilts A.+JD T. N*VF WO"4fEb A---rVaj{ -M PZMaAE
/VDN tJAT`1V`6 �Vt~c(G-s. APJD PLANT KOA Ain oRilk 7ReVR5 .
w"E At-60 PI-AOT AjQ3> H*eVt--S7 t3ArqA#JAs . PAPAYA, kt--)D UXA/A_
etitioner's Signature
STATE OF HAWAII )
SS.
COUNTY OF HAWAII )
On this day of 120 before me personally appeared
, to me known to be the person described in and who executed
the foregoing instrument, and acknowledged that he executed the same as his free act and deed.
SEE ATTACHED
CA JURAT Notary Public, State of Hawaii
My commission expires:
Appendix A
J U RAT
A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of Scacmnnem
Subscribed and sworn to (or affirmed) before me on this [may of"V-6 '1 ,
20` by Yr. 010YV V1 Cjs .
proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.
'eft.o A MONDRAGON
Commission f2264992
a , Notary Pudic-Cadfomia
San Luis ODW County
Comm Exprss APR 12,2023 1
Signature U (Seal) f
OPTIONAL INFORMATION INSTRUCTIONS
The wording of all Jurats completed in California after January 1,2015 must be in the form
as set forth within this Jurat.There are no exceptions.If a Jurat to be completed does not
follow this form,the notary must correct the verbiage by using a jurat stamp containing the
correct wording or attaching a separate jurat form such as this one with does contain the
proper wording. In addition, the notary must require an oath or affirmation from the
DESCRIPTION OF THE ATTACHED DOCUMENT document signer regarding the truthfulness of the contents of the document. The
document must be signed AFTER the oath or affirmation.If the document was previously
L rl 1'L Q N �'
ry(Z r1k-&,r b t0 4 JJU jk signed,it must be re-signed in front of the notarypublic during the jurat process.
(Title or description of attached document)
. .� a State and county information must be the state and county where the
document signer(s)personally appeared before the notary public.
(Title or description of attached document continued) • Date of notarization must be the date the signer(s) personally
appeared which must also be the same date the jurat process is
Z completed.
Number of Pages Document Date l?� • Print the name(s) of the document signer(s)who personally appear at
the time of notarization.
• Signature of the notary public must match the signature on file with the
Additional information office of the county clerk.
• The notary seal impression must be clear and photographically
reproducible. Impression must not cover text or lines. If seal impression
smudges, re-seal if a sufficient area permits, otherwise complete a
different jurat form.
ee Additional information Is not required but could help
to ensure this jurat is not misused or attached to a
different document.
Indicate title or type of attached document, number of
pages and date.
• Securely attach this document to the signed document with a staple.
2015 Version www,Nota ryC lasses.corn 800-873-9865