Check all that apply: Major Facility Major Modification Collocation Substantial Change

Community Development Department 14000 City Center Dr., Chino Hills, CA 91709 (909) 364-2780 Fax (909) 364-2795 www.chinohills.org CUP No.: TDA No.: Submittal Date: CONDITIONAL USE PERMIT FOR WIRELESS COMMUNICATION FACILITIES This application is required for wireless communication facilities as defined in Section 16.44 of the Chino Hills Municipal Code. Wireless Carrier: Project Name: Project Address: APN: Is the Project located in the Public Right-of-Way? Yes No Zoning District: General Plan Land Use: Check all that apply: Major Facility Major Modification Collocation Substantial Change Project Description: Located within a Residential Zone CONTACT INFORMATION Applicant (Main Contact Person): City, State, Zip: Phone No.: Email: Property Owner: City, State, Zip: Phone No.: Email: Wireless Carrier Contact: City, State, Zip: Phone No.: Email: APPLICATION SUBMITTAL REQUIRES AN APPOINTMENT WITH THE PLANNING DIVISION. PLEASE CALL (909) 364-2750 TO SCHEDULE AN APPOINTMENT. SEPARATE APPLICATIONS AND FEES WILL BE REQUIRED FOR MULTIPLE FACILITIES. FURTHER INFORMATION AND SUBMITTAL REQUIREMENTS ARE NOTED ON THE FOLLOWING PAGES. Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2035 - CUP Info & Appl for Wireless Facilities.docx Revised: 12/18/2018 Page 1 of 10

APPLICABILITY If the answer to any of the questions below is Yes, the project qualifies under a Conditional Use Permit for Wireless Communications Facilities. Criteria: Yes No 1. Is the facility ground mounted or a structure specifically designed for a wireless communication facility? 2. Is the project a modification that substantially changes an existing wireless communication facility? 3. Is the project a collocation that substantially changes an existing wireless communication facility? 4. Is the project located within a residential zone? THIS FOLLOWING CHECKLIST MUST ACCOMPANY THE APPLICATION UPON SUBMITTAL. SUBMITTAL REQUIREMENTS The following items must be provided at time of submittal: One (1) Copy Application, completed, signed and dated by property owner and/or authorized agent. Initial Deposit Conditional Use Permit Application. Refer to the Community Development Fee/Deposit Schedule for the amount. One (1) Copy Trust Deposit Account Procedures/ Agreement form. Shall be signed and dated. One (1) Copy Land Use Questionnaire (pages 11-15 of this packet). All Owners must sign the Property Owner s Authorization Application Certificate. The notarized power of attorney must contain the names of all owners. Fifteen (15) Sets Project Plans (minimum 24 x 36 ), shall include plot plan; any proposed grading and/or trenching; site plans; elevations drawn at a scale to accurately delineate the proposed project; and equipment details for all new and existing equipment associated with the communications facility. (Shall be bound together and folded accordion style 8 x 11 size.) (Refer to the plot plan checklist for specific requirements. A conceptual plan is not acceptable.) One (1) Digital Copy Project plans, photo simulations and required technical studies in PDF format. One (1) Copy City approved site plans. Modified and collocated facilities shall require the submittal of City approved site plans and elevations, and conditions of approval. This information can be obtained by submitting a Records Request to the City Clerk. One (1) Copy Project Plans, reduced to 11 x 17. Three (3) Copies Photo Simulations. Shall be of the proposed facility, before and after, drawn to scale, and in color. One (1) Copy Variance Application (if needed). Shall be signed and dated. One (1) Copy Preliminary Title Report. Shall be current, within the past 60 days. One (1) Copy Recorded Grant Deed, or Quit Claim Deed. One (1) Copy Letter of Intent. Shall clearly indicate the intended use associated with the proposal, along with a brief narrative accompanied by written documentation that explains and demonstrates the applicant's efforts to locate the facility in accordance with the screening and site selection guidelines. One (1) Copy Summary Letter. If a Pre-Application Conference was conducted, a summary letter of the conference will be required. Three (3) Copies Required Technical Studies. Shall be reviewed and approved by the City before the application may be deemed complete. Page 2 of 10

Radio Frequency (RF) Emission Analysis. Shall show before and after coverage area maps, and site locations throughout the City, etc. Letter from the RF Engineer. Shall indicate that the proposed facility is in compliance with all FCC and California Public Utilities Commission (PUC) requirements. Alternative Site Analysis. Shall demonstrate alternative sites were considered with the following criteria; location, design, impact on aesthetics and welfare of the surrounding community, and the screening and site selection guidelines in Section 16.44 of the Chino Hills Municipal Code. One (1) Copy Assessor s Parcel Map. Shall be specific to the project with a redline/black line drawn showing a 500 foot radius from the project property if the proposed location is within the public right-of-way. For all other locations, show a 300 foot radius line identifying the surrounding property owners. Please contact the San Bernardino County Assessor s Office. Three (3) Sets and One (1) Xerox Copy Mailing labels. Labels shall list the names and addresses of the surrounding property owners which correspond with the 500 foot radius line from the project property for projects located within the public right-of-way, or a 300 foot radius line for all other locations. One (1) Copy Receipt of payment of Fire Review fees or letter stating such fees are not applicable. (Payment of these fees may be accomplished at the Chino Valley Independent Fire District, located at 14011 City Center Drive, Chino Hills, CA 91709. Please contact the Fire District at (909) 902-5280 regarding Fire Review fees. Please note: The Community Development Director or his or her designee may require additional information, as appropriate, for applications proposing a new, or substantial change to, a tower or base station. I certify under penalty of perjury that I am the legal representative for the project, that all required submittal documents have been submitted, that the proposed facility is in compliance with all FCC and California Public Utilities Commission (PUC) requirements, that I understand the following requirements, and that the foregoing information is true and accurate to the best of my knowledge. SPECIFIC PLOT PLAN REQUIREMENTS SITE PLAN TO BE DRAWN TO SCALE ON ONE SHEET (MINIMUM 24 X 36 ) SHOWING THE FOLLOWING ITEMS: Vicinity Map. Names, addresses and telephone numbers of the record owner, applicant and the person preparing the map. Legal description and Assessor s Parcel Number of the property involved. Clearly identify all existing utilities, indicate names, addresses and telephone numbers of: a) water company, b) sewage disposal, c) electric, d) gas, e) telephone, f) cable television. If existing utilities are unavailable, please indicate method of supply. Provide detailed description of the project including the use of each existing and proposed structure and/or open storage areas. North arrow, date of drawing and ENGINEER S scale (suggest 1:20 or 1:30) or ARCHITECT S scale (suggest ¼ = 1 or 1/8 = 1 ). Location, width and names of streets and recorded easements on property. Location of all existing road improvements and driveways. Delineate the dimensions of property lines or boundary lines of property that the project is located within. Indicate project boundary lines if only a portion of the project is to be developed. Page 3 of 10

Include a floor plan of the equipment area. Clearly delineate the setback area. Clearly delineate the dimensions of the lease area of the proposed project (lease area of the wireless communications facility and equipment including any equipment enclosures). Clearly identify all existing and proposed wireless communications facilities. Note: If the existing facility will be modified to allow the collocation of a new facility, then existing wireless provider(s) shall be identified and existing equipment shall be shown. Location, size (dimensions), and number of proposed equipment cabinets. Location, size and use of all existing and proposed buildings and structures, including dimensions, square footage, distance from property lines, and building separation. Submit a letter of intent clearly indicating all intended uses associated with the proposal, which clearly identifies the specific areas in which uses will be conducted. Indicate the current land uses for the project site and the surrounding properties. Indicate existing General Plan Land Use District designation of the project site. Indicate General Plan Land Use District classification on all adjacent properties including property across any streets. These designations should be depicted at the appropriate site in relation to the project. Indicate type of development on all adjacent properties, including across any streets. Show distance of structure(s) on adjacent properties that are within 20 feet of property project line. If no structures exist, please indicate this by a note. Indicate type of construction and approximate age (if known) of any existing structures. Locate by distance in relation to other structures and property lines, and indicate existing structures that are to remain or be removed. Indicate height, building footprint dimensions (including eave overhang projections), square footage of each story and number of stories, including basements. Show parking spaces in detail. Refer to the City s Development Code for detailed information regarding parking requirements for your use and for ADA parking requirements. Show loading zone space(s) (10 x20 ), if required for maintenance of the wireless communications facility. Indicate any topography (unusual drainage or hilly terrain) that might affect the building site, parking area or access by flow line arrows and contour lines. Show existing rough grade contours and finish contours. Show finish elevations at lot corners and graded areas. Show typical lot drainage and swales. Indicate on site plan if grading is not required. Show location and size of any proposed retaining walls. All grading is subject to the California Building Code, City Municipal Code, or any related City ordinance. Show the percentages of parcel covered by buildings, paving, landscaping, and open space. Show location, size and type of all trees, and indicate whether any trees are to be removed. If a variance is requested, indicate by a note the following: a) What is the variance for? b) Where is the proposed variance located on the project site? C) Why the variance should be granted per sections 16.70.060 or 16.72.060 of the Chino Hills Development Code. Please complete a Variance Application Page 4 of 10

for any Variance requested. INFORMATION AND PROCEDURES This is an Actual Cost application. The actual cost for a project is determined according to the time spent by personnel on that project and the associated personnel benefits, department overhead, and other costs incurred for that project. Initial Deposits are determined by the fee schedule adopted by City Council. Refer to the Community Development Fee/Deposit Schedule for application fee amounts. Once the application is assigned to a project manager, an estimated budget will be prepared based on the scope of the project, including the amount of time spent on the project. The deposit of additional funds shall be required if the Trust Deposit Account falls below 25% of the budget remaining for the project. Notification of additional deposit required will be mailed to the applicant, who shall deposit such additional monies prior to the date specified in the notice. Projects will not be completed with money due. If the additional deposit is not made by the date specified in the notice, the project shall be suspended, without further action on the part of the City. Before submitting your application, the City encourages you or your representative to discuss your development proposal with the Planning Division staff at the Community Development public counter or on the phone by calling the Planning Division at (909) 364-2740. For projects that require information from multiple divisions and departments within the City, a pre-application conference or consultation may be appropriate. Once a pre-application is submitted, the Project Review Committee (PRC) will meet to discuss the project, identify potential issues, and determine if technical studies will be required with the formal application. Once a formal application is submitted, the application will be scheduled for a PRC meeting, where staff from the different departments and divisions will comment on the proposal, discuss whether the application is complete or incomplete, and identify any corrections that are required on the project plans. If the application is deemed complete and there is no correction that must be made on the plans, then the PRC will discuss conditions of approval, and make a recommendation to the Community Development Director. If the application is deemed incomplete and/or corrections are required, the applicant shall submit the additional information that is required to make the application complete and provide revised plans. Once the revised plans are submitted, the PRC will review the plans, determine the completeness of the application and identify any outstanding issues on the plans. This process repeats until the application is deemed complete. Once the application is deemed complete, the Project Manager will conduct an initial environmental review, called an Initial Study, to determine if additional information is required to complete the environmental review. If additional information is not required, the Project Manager will determine the type of environmental document that is required for the project as required by the California Environmental Quality Act (CEQA), such as a Negative Declaration, or Environmental Impact Report (EIR). Subsequently, the Project Manager will prepare the appropriate environmental document and request Conditions of Approval from the PRC. If an EIR is required for the project, the City will prepare the environmental document. The cost of preparing the EIR must be paid by the developer prior to the commencement of work on the EIR. Once the environmental document is complete and the project is ready for a Planning Commission hearing, the Project Manager will make the environmental document available for public review, send copies to the appropriate agencies and persons who request the document for review in accordance with the CEQA Guidelines, and provide notice of the public hearing in accordance with Section 16.58 of the Chino Hills Municipal Code. The Planning Commission will make a decision to either approve or deny the project at a public hearing. Any decision made by the Planning Commission is appealable directly to the City Council in accordance with Section 16.58.070 of the Chino Hills Municipal Code. DEVELOPMENT REQUIREMENTS: 1. The facility shall not bear any signs or advertising devices other than certification, warning, or other required seals or required signage. Page 5 of 10

2. Any and all accessory equipment, or other equipment associated with the operation of the facility, including but not limited to, transmission cables, shall be located within a building, enclosure, or underground vault in a manner that complies with the development standards of the zoning district in which such equipment is located; whenever feasible, accessory equipment or other types of equipment shall be located underground. In addition, if equipment must be located above ground, it shall be visually compatible with the surrounding buildings and either screened by sufficient landscaping to shield the equipment from view, or designed to match the architecture of adjacent buildings. If no recent and/or reasonable architectural theme is present, the Director or his or her designee may require a particular design that is deemed by the Director to be suitable to the subject location. 3. The facility exterior shall be comprised of nonreflective material(s) and painted or camouflaged to blend with surrounding materials and colors. 4. The site of the facilities shall be maintained in a condition free of debris, refuse, and trash. All graffiti shall be removed within 48 hours. 5. Any and all screening used in connection with a wall mounted and/or roof mounted facility shall be compatible with the architecture, color, texture and materials of the building or other structure to which it is mounted. 6. Access to the facility shall be limited to existing access roads only. No grading or construction of new roads, either paved or unpaved, is permitted for the purpose of providing access to the facility unless otherwise approved by the City, based upon a determination at the City's sole discretion, that a new road will not have any significant impacts on the property upon which the new road will be constructed or on any surrounding properties. 7. For facilities installed on existing utility structures, the facility owner must obtain the written permission of the utility structure owner and any underlying property owner. 8. The facility shall maintain maximum clearance consistent with current Americans with Disabilities Act (ADA) requirements. 9. The facility shall be considered an accessory structure and shall comply with the setback requirements for the zone in which the facility is located. Screening and Site Selection Considerations: 1. The extent to which the proposed facility blends into the surrounding environment or is architecturally integrated into a concealing structure, taking into consideration alternate sites that are available; 2. The extent to which the proposed facility is screened or camouflaged by existing or proposed new topography, vegetation, buildings, or other structures; 3. The proposed facility is a stealth facility; 4. The total size of the proposed facility, particularly in relation to surrounding and supporting structures; 5. The selection process of the proposed facility shall conform to the following order of preference (item "a" being the most preferred): a. Located within City-owned property b. Collocated with an existing facility c. Attached to an existing structure such as an existing building, communication tower, church steeple or utility pole or tower d. Located in an industrial/business park zoning district e. Located in a commercial zoning district f. Located in the public right-of-way 6. A major facility should be located at least (1,000) feet from the nearest existing, legally established major facility (except in the event that such facility is collocated); Page 6 of 10

7. A ground mounted facility should be located in close proximity to existing above ground utilities, such as electrical tower or utility poles (not scheduled for removal or under grounding in the next eighteen (18) months), light poles, trees of comparable height, water tanks and other areas where the facility will not detract from the image or appearance of the City; 8. A ground mounted facility should be covered with a clear anti-graffiti material of a type approved by the Director or designee; 9. A roof mounted facility that extends above the existing parapet of the building on which it is mounted should be screened by a material and in a manner that is compatible with the existing design and architecture of the building; and 10. A roof mounted facility, and any guy wires, supporting structures and accessory equipment should be located and designed so as to minimize visual impact as viewed from surrounding properties and public streets. Location Requirements: 1. The wireless communications facility tower shall not be located within two hundred (200) feet of any residential property line. 2. A ground mounted facility shall be located in the rear yard or side yard of a property; provided that no part of a ground mounted facility shall be located in a side yard that abuts any public street. 3. No portion or extension of a major facility, including without limitation any guy wires, shall protrude beyond property lines or extend into any portion of property where such facility is not itself permitted. Design Requirements: 1. A ground mounted facility and associated equipment shall be screened and enclosed with a wall. The design shall be approved by either the Director or designee or the Planning Commission as appropriate. 2. A ground mounted facility shall not be located in a required parking area, vehicle maneuvering area, or vehicle and/or pedestrian circulation area in such a manner that it interferes with, or in any way impairs, the utility or intended function of such area. Height Requirements: 1. No major facility, nor any major modification, shall exceed thirty-five (35) feet in height for nonresidential areas, regardless of any other provision in this code. 2. No minor facility shall exceed twenty-five (25) feet in height within a residential zone or within two hundred (200) feet of a residential property line, regardless of any other provision in this code. 3. Maximum heights shall be measured from lowest adjacent grade to the highest point of the facility. 4. No major facility, major modification, nor minor facility in a residential zone may exceed the maximum building height set forth in this section, unless an adjustment is granted by the Planning Commission after making all of the following findings: a. The Planning Commission has reviewed alternative options provided by the applicant and staff, including, but not limited to, additional and/or different locations and designs, and has determined that the application as approved with the additional height has a lesser impact on the aesthetics and welfare of the surrounding community as compared to other alternatives; b. Based on the evidence presented, the additional height above the maximum is reasonably necessary for collocation of wireless communication facilities or for the efficient operation of the proposed facility; and Page 7 of 10

Required Findings: c. The additional height above the maximum is required to ensure compliance with federal or state law. 1. The proposed facility meets all applicable standards and requirements set forth in Section 16.44 of the Chino Hills Municipal Code. 2. The proposed facility has been designed to minimize its visual and environmental impacts, including the utilization of stealth technology, when applicable. 3. The proposed site has the appropriate zoning, dimensions, slope, design, and configuration for the development of a facility. 4. That general landscaping consideration, when applicable to the facility, has been complied with to complement the structures and antennae, provide an attractive environment and preserve natural features and elements. 5. Based on information submitted, the proposed facility is in compliance with all FCC and California Public Utilities Commission (PUC) requirements. 6. The applicant has demonstrated and confirmed that the facility is necessary to close a significant gap in the provider s coverage and there is no less intrusive means to close that significant gap unless determined that the facility is a modification. Discontinued/Abandoned Facilities: Any discontinued or abandoned facility shall be removed in accordance with Section 16.44 of the Chino Hills Municipal Code. STANDARD PROJECT CONDITIONS OF APPROVAL 1. All wireless communication facilities which are erected, located, or modified within the City shall comply with Section 16.44 of the Chino Hills Municipal Code, including all wireless communication facilities for which building permits have expired. 2. Permit approval is attached to the specific facility in which the permit application was made, unless suspended or revoked by the City. 3. Regardless of any permit that may be granted in accordance with Section 16.44 of the Chino Hills Municipal Code, the facility shall be installed, and at all times, maintained in compliance with the requirements of the Building Code of the City. Applicants are separately required to obtain all applicable building and construction permits that may be required prior to erecting or installing the facility. Facilities located within the public right-of-way require the applicant to obtain a separate encroachment permit from the Engineering Division. 4. Any lease of City-owned property for the purpose of erecting a wireless communications facility shall require a negotiated lease agreement and/or such other license, franchise, or other specified right granted by the City in accordance with the Chino Hills Municipal Code. If a lease agreement from the City is required, then said lease agreement shall be in place prior to the issuance of any applicable building and construction permits for said communication facility. If a modification is proposed to an existing communication facility located on City-owned property, then an amendment to the existing lease agreement shall be executed prior to the issuance of any applicable building and construction permits for said communication facility. The existence of a lease agreement or other license shall not relieve the applicant of any obligations to obtain appropriate permits as required by Section 16.44 of the Chino Hills Municipal Code. 5. All telecommunication equipment and other components of the wireless communications facility shall not bear any signs or advertising devices other than certification, warning, or other required seal or required signage. Page 8 of 10

6. The wireless communications facility shall be maintained to provide a high-quality appearance at all times. 7. The antennas, radome, equipment, and any other component of the wireless communications facility shall be enclosed and concealed within the tower screening structure and/or the walled facility enclosure. Wireless communications facility equipment and components shall not be visible from the exterior of the facility. 8. All accessory equipment or other equipment associated with the operation of the facilities, including, but not limited to, transmission cables, shall either be screened or located within a building, enclosure, or underground in a manner that complies with the development standards for the project. 9. The exterior of all wireless communications facilities shall be comprised of non-reflective material(s), as approved by the City. 10. No wireless communications facility shall be located in a required parking area, vehicle maneuvering area, or pedestrian circulation area in such a manner that it interferes with, or in any way impairs, the utility or intended function of such area. 11. No wireless communications facility or accessory equipment installed or operated as part of the wireless communications facility shall interfere with any City emergency transmission, signal, or form of communication. 12. This Conditional Use Permit (CUP) shall become null and void if all conditions of approval have not been complied with and the Permit is not used within three (3) years of the date of approval. The Planning Commission may grant one extension of time for a period not to exceed one (1) year, provided an application requesting the extension is filed with the Planning Division no less than 30 days prior to the expiration of the Permit. Used as referred to in this Condition means the commencement of substantial construction activity or any activity authorized by the approval. If an extension of time is not granted, the CUP shall expire and a new application shall be required. 13. The applicant or its successors in interest shall indemnify, protect, defend (with legal counsel reasonably acceptable to the City), and hold harmless, the City, and any agency or instrumentality thereof, and its elected and appointed officials, officers, employees, and agents from and against any and all liabilities, claims, actions, causes of action, proceedings, suits, damages, judgments, liens, levies, costs, and expenses of whatever nature, including reasonable attorney s fees and disbursements (collectively Claims ) arising out of or in any way relating to this project, any discretionary approvals granted by the City related to the development of the project, or the environmental review conducted under California Environmental Quality Act, Public Resources Code Section 21000 et seq., for the project. If the City Attorney is required to enforce any conditions of approval, the applicant shall pay for all costs, including attorney s fees. 14. The applicant and project shall comply with requirements of all Federal, State, County, and local agencies as are applicable to this project. 15. Any amounts of flammable or combustible liquids or any hazardous materials stored or used on the site must be reviewed and approved by the Chino Valley Fire District. 16. If the project is ever discontinued, abandoned, or no longer in operation, the owner and/or operator of the facility shall remove the wireless communications facility and return the project site to its original condition pursuant to Section 16.44 of the Chino Hills Development Code. 17. The permissible construction hours and operations for the project shall be as follows: a. Construction shall be limited to the hours of 7:00 a.m. to 7:00 p.m. Monday through Friday, 8:00 a.m. to 6:00 p.m. Saturday, and shall be prohibited on Sundays and City listed Federal holidays in order to minimize disruption to existing residential neighborhoods. Construction activities entirely within the existing building that do not cause significant noise, vibration, or other impact at the exterior of the building may be permitted outside of the construction hours, with the approval of the Community Development Director or his/her designee. Such approval may be revoked by the Community Development Director or his/her designee if the Community Development Director determines that surrounding properties and/or uses are adversely Page 9 of 10

impacted by the construction activities. b. During construction, best efforts shall be made to locate stockpiling and/or vehicle staging areas as far as practicable from existing residential dwellings. c. All construction vehicles or equipment, fixed or mobile, operated within 1,000 feet of a dwelling unit shall be equipped with properly operating and maintained mufflers. 18. All areas within the project site shall be maintained free of trash and debris. 19. Noise emanating from the project shall not exceed the noise standards and shall be in compliance with all requirements as stated in Section 16.48 of the Chino Hills Municipal Code. 20. Any graffiti shall be removed within forty-eight (48) hours of being reported. Further, the operator of the facility shall apply a coating to the enclosure walls that facilitates the removal of any graffiti. 21. Trust Deposit Account(s) shall show no deficit(s). If the Trust Deposit Account(s) associated with the project shows a negative balance, the project construction shall cease, including inspections, until such time as sufficient funds are deposited to return the account(s) to a positive balance. Page 10 of 10

Community Development Department 14000 City Center Dr., Chino Hills, CA 91709 (909) 364-2740 Fax (909) 364-2795 www.chinohills.org Related Case No(s): Submittal Date: LAND USE QUESTIONNAIRE This document is required in conjunction with following applications: Conditional Use Permit (including Wireless), General Plan and Municipal Code Amendments, Major Variance, Planned Development, Pre-Application Review, Site Plan Review, Tentative Parcel Map/Minor Subdivision and Gate Guarded Neighborhood Plan. Applicant: All sections must be completed in their entirety or the application will not be accepted. If the answer is unknown or the question is not applicable, please indicate, as appropriate. If additional space is needed, please use attachments. APPLICANT INFORMATION: Applicant: Address: Phone: Email: Contact Person: Phone: Email: PROJECT LOCATION: Project Address: Side of Street: Nearest Cross Street: Assessor Parcel Number: Tract: Lot: Current Current General Zoning District: Plan Land Use: Parcel Size: PROJECT DESCRIPTION: (provide in-depth details) PROPOSED PROJECT INFORMATION: (If Applicable) Proposed Proposed General Zoning District: Plan Land Use: APPLICATION CONTINUED ON NEXT PAGE Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2026 - Land Use Appl Questionnaire - (New).docx Revised: 12/18/2018 1 of 5

SITE INFORMATION: (Please provide in-depth details) 1. Describe the existing development within 300 feet of the site. 2. Is the site within a Planned Development (PD)? No Yes If Yes : Which PD? 3. Are there any deed restrictions, covenants, conditions and restrictions (CC&Rs), or other restrictions that affect the property? No Yes (if Yes, explain below) 4. Identify if the site is presently served by the following utilities: Electricity No Yes Gas No Yes Water No Yes Sewer No Yes Telephone No Yes If No, have any contacts been made with the agencies providing these services? No Yes If Yes, please provide information and/or attach correspondence: 5. Are there any potential hazardous materials on or near the project site? No Yes Please provide appropriate Phase 1 and/or 2 Environmental Site Assessment Report. PROJECT CONSTRUCTION INFORMATION: 1. Will your project require any permits from local, state or federal agencies? No Yes If Yes, which agency and permit description: APPLICATION CONTINUED ON NEXT PAGE Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2026 - Land Use Appl Questionnaire - (New).docx Revised: 12/18/2018 2 of 5

2. Will any earth material be exported from or imported to the site? No Yes If Yes, please indicate the approximate quantity in cubic yards, whether imported or exported and the location of the borrow pit or dump site? 3. Approximately how many square feet of impermeable surface (building and paving) will be created by the development of the proposed project? Please express in square feet and as a percentage of the whole site. 4. What is the projected opening year or first phase for the project? 5. Is the project proposed in phases? No Yes If Yes a phasing plan may be required. Please describe the phasing. PROJECT OPERATIONAL INFORMATION: Provide the following information for all industrial, commercial, professional office or institutional projects (churches, social care facilities, private schools, etc.). 1. Provide an estimate of how many people will work at and visit the project each day or will stay overnight at the project site, per use. If school or social care facility, state age and numbers of students/patients and staff. 2. Indicate the days and hours of operation anticipated for each use proposed for the project site. APPLICATION CONTINUED ON NEXT PAGE Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2026 - Land Use Appl Questionnaire - (New).docx Revised: 12/18/2018 3 of 5

DOCUMENT CERTIFICATION: I certify that under penalty of perjury that I am the (check one below) and that the foregoing information is true and accurate to the best of my knowledge: Legal Owner (all names that appear on the Deed must sign their names) Owner s Legal Agent I further certify that the statements furnished in this application, and in the attachments thereto, present the data and information required to adequately evaluate the proposed project to the best of my ability, and that the facts, statements, and information presented are true and correct to the best of my knowledge. I further understand that additional information may be required to be submitted to the City of Chino Hills before an adequate evaluation of the proposed project can be made. Date: PROPERTY OWNERS AUTHORIZATION All property-owners of record must sign this application certificate. I (we), the undersigned owner(s) or officer(s) in the organization, owning the land(s) for which this application is made, state that I (we) is (are) aware that the application is being filed with the City of Chino Hills Community Development Department and I (we) certify under penalty of perjury that the information contained in the application is true and correct. I (we) further agree that if any information proves to be false or incorrect, the City and any special purpose or taxing district affected thereby are and shall be released from any liability incurred if the application is approved. Any persons signing with Power of Attorney for the property-owner(s) must print the names of those individual(s) in the signature block and attach a Notarized copy of the Power of Attorney. PROJECT SITE APN(s): Owner/Agent Signature(s) If signed by Legal Agent, provide name(s) of property owner(s): ADDITIONAL REQUIRED FORM ON NEXT PAGE Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2026 - Land Use Appl Questionnaire - (New).docx Revised: 12/18/2018 4 of 5

Community Development Department 14000 City Center Dr., Chino Hills, CA 91709 (909) 364-2740 Fax (909) 364-2795 www.chinohills.org CERTIFIED SURROUNDING PROPERTY OWNERS LIST DECLARATION The list is required to provide surrounding property owners notification of the public hearing for the proposed project and is valid for six (6) months. If the original list is more than six (6) months old, a new list must be provided for the public hearing notification. This list includes all properties: 300 foot radius from project site 500 foot radius from project site* Adjacent to project site EXAMPLE: Assessor s Parcel Name Address City, State, Zip Code * Automobile Maintenance, Automobile Service Stations and Car Wash Uses require 500 feet of notification. I (we), the undersigned owner(s) or officer(s) in the organization owning the land(s) for which this application is made, state that I (we) is (are) aware that the application is being filed with the City of Chino Hills Community Development Department and that I (we) certify under penalty of perjury that the information contained in this application is true and correct. I (we) further agree that if any such information proves false or incorrect, the City of Chino Hills and any special purpose or taxing district affected thereby are, and shall be, released from any liability incurred if the application is approved. Any persons signing with Powers of Attorney for the property-owner(s) must print the names of those individuals in the signature block and attach a notarized copy of the Power of Attorney. I certify under penalty of perjury that I am the (check one below) and that, to the best of my knowledge, the enclosed list contains the name and addresses of all persons to whom all property is assessed as they appear on the latest equalized assessment roll maintained by the County Assessor or Tax Collector. Legal Owner (all names that appear on the Deed must sign their names) Owner s Legal Agent PROJECT SITE APN(s): Owner/Agent Signature(s) If signed by Legal Agent, provide name(s) of property owner(s): Applications and fees are subject to change. Please visit our website for the most current version of this application. S:\CD ADMINISTRATION\Applications & Forms\Planning\CDPD_2026 - Land Use Appl Questionnaire - (New).docx Revised: 12/18/2018 5 of 5