CDA - Annual Cannabis Permit (ACP) Renewal Application

Annual Cannabis Permit (ACP) Renewal Application
ACP or CCP Number
XXXXnn-nnnn
Site Address

Street Address

Street Address Line 2

CityState

Zip Code
APN:
APN:
APN (additional):
APN (additional):
Employees
Employment Type
Number of Employees
Tax Identification Number
Tax Identification Number
ADP or CCP Reference Number
ADP or CCP Reference Number
Change in Site Activities from ADP or CCP Approval
Is your Surety Bond still in effect?
Complete Description of Cultivation/Activities

Complete Description of Cultivation/Activities0/100

Property Owner Name
Owner Name
Owner Name
Owner Address

Street Address

Street Address Line 2

CityState

Zip Code
Owner Phone Number
Owner Phone NumberFormat: (000) 000-0000.
Owner Fax
Owner Fax NumberFormat: (000) 000-0000.
Owner Email
Owner Email
(Owner) Resident at Cannabis Cultivation Location

Applicant/Agent
Applicant/Agent
Applicant/Agent Name
Name
Applicant/Agent Address

Street Address

Street Address Line 2

CityState

Zip Code
Applicant/Agent Phone Number
Phone NumberFormat: (000) 000-0000.
Applicant/Agent Fax
Fax NumberFormat: (000) 000-0000.
Applicant/Agent Email
Applicant/Agent Email
(Applicant/Agent) Resident at Cannabis Cultivation Location

Change in Property Residents From ADP/CCP Approval

(attach additional sheets is needed)
Name (Change in Prop. Residents)
Name (Change in Prop. Residents)
Address (Change in Prop. Residents)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (Change in Prop. Residents)
Phone NumberFormat: (000) 000-0000.
Fax (Change in Prop. Residents)
Fax NumberFormat: (000) 000-0000.
Email (Change in Prop. Residents)
Email (Change in Prop. Residents)
Are there additional residents?
Upload Additional Resident's Information

Cancelof

Change in Entities With Financial Interest From ADP/CCP Approval

(attach additional sheets is needed)
Name (Change in Entities)
Name (Change in Entities)
Address (Change in Entities)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (Change in Entities)
Phone NumberFormat: (000) 000-0000.
Fax (Change in Entities)
Fax NumberFormat: (000) 000-0000.
Email (Change in Entities)
Email (Change in Entities)
Please indicate if there are additional entities:
Upload Additional Entities' Information

Cancelof

By initialing here, you attest to the following:
Initials:

By initialing here, you attest to the following:
Initials
REVIEW AND CHECK ALL OF THE FOLLOWING

I hereby authorize the County of Nevada Community Development Agency employees and/or any other appropriate County or State agency or local districts to enter the property to conduct site inspections and investigations as set forth in this permit that may be issued on the basis of this application. I further agree to pay any fee for such inspection or investigation that occurs on the subject property.
Hidden Checked

I hereby authorize the County of Nevada Community Development Agency employees and/or any other appropriate County or State agency or local districts to enter the property to conduct site inspections and investigations as set forth in this permit that may be issued on the basis of this application. I further agree to pay any fee for such inspection or investigation that occurs on the subject property.
Please upload the following documents: Proof of Surety Bond, Toilet Contract (if applicable), Biological Memos (if applicable)

Cancelof
APPLICANT’S DECLARATION

By my signature below, I certify that I am the property owner or authorized to act on the property owner’s behalf. I have read this permit application and the information I have provided is true and correct. I agree to comply with all applicable County ordinances and State laws.
Printed Name
Printed Name
Signature*
Signature
Date

MonthDayYear
Should be Empty:

Annual Cannabis Permit (ACP) Renewal Application

Property Owner Name

Applicant/Agent

Change in Property Residents From ADP/CCP Approval

Change in Entities With Financial Interest From ADP/CCP Approval

Initials:

APPLICANT’S DECLARATION