Form 43-84, the Sexually Oriented Business Attestation Form, is a City of Irvine form in which a prospective operator agrees to the location standards and operating conditions for a sexually oriented business. It is filed with the Sexually Oriented Business Permit development case application (PSX), and the City also lists obtaining an Irvine business license among the requirements before operating. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form is published by the City of Irvine at cityofirvine.gov.
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What is 43-84?
Form 43-84, Sexually Oriented Business Attestation Form, is the City of Irvine Community Development form on which an applicant marks an X for each listed standard and operating condition and certifies under penalty of perjury that the information is true.
The form is issued by Planning & Development Services and must be filed with the Sexually Oriented Business Permit development case application (PSX). It has three parts: applicant information, a list of attestations, and an agreement with signature block. Standards A through L cover where and how the business is built: the General Industrial or IBC Industrial zone, separation of 2,300 feet from residential zones and uses and from religious institutions, public parks, child care centers and schools, a 500-foot separation from another sexually oriented business, parking, signs, design, traffic and noise. Operating conditions M through AA cover matters such as hours (no operation between 10 p.m. and 7 a.m.), age limits, the manager's station, lighting, restrooms, live entertainment, security guards and public nudity.
The form warns that receiving a permit does not authorize you to operate unless you comply with Irvine Zoning Ordinance (IZO) Chapter 2-28 and all applicable federal, state and local regulations. It is not a business license: the City lists obtaining a business license as a separate requirement. If the business is found not to comply, the permit may be revoked under IZO Section 2-28-10.
Who needs to file 43-84?
Prospective operators of a sexually oriented business in the City of Irvine who are applying for a Sexually Oriented Business Permit complete Form 43-84. The City requires it before operating, together with the development case application (PSX) it must be filed with.
Points the form attaches to the applicant:
- The applicant marks an X in each box to show agreement with all listed standards and conditions (A through AA).
- Under standard R, neither the applicant (if an individual) nor any officer or general partner (if a corporation or partnership) may have been found guilty within the past two years of violating a sexually oriented business permit or similar license in any city, county, territory or state, or of a misdemeanor or felony the state classifies as a sex-related offense, including the Penal Code sections the form lists.
- The applicant prints a name, signs and dates the agreement.
The form does not describe who may sign for an applicant, so the signature block is for the applicant. It is not a general business license form and does not replace the other items the City requires.
When to file 43-84
File Form 43-84 before you operate a sexually oriented business, at the same time as the Sexually Oriented Business Permit development case application (PSX). The form says it must be filed with that application, so it has no separate due date of its own.
The City's list of requirements before operating includes the completed development case application, the developer deposit case setup form, the electronic/digital signature disclosure (if actual signatures are not included on the application and deposit forms), this attestation form, payment of the initial deposit fee and a business license. The form's office-use block records a permit expiration date, but the form itself prints no renewal rule or processing time.
Documents you need
- Completed development case application for the Sexually Oriented Business Permit (PSX); Form 43-84 must be filed with it.
- Developer deposit case setup form, submitted with the application package before operating.
- Electronic/digital signature disclosure, only if actual signatures are not included on the application and deposit forms.
How to fill out 43-84
Enter contact and business names
In APPLICANT INFORMATION, type the CONTACT NAME and the BUSINESS NAME.
Enter address, phone and email
Fill in BUSINESS or PERSONAL ADDRESS, SUITE, CITY, STATE, ZIP, PHONE and EMAIL. The address, phone and email labels carry an asterisk on the form.
Read the notice to applicants
Read the NOTICE TO ALL APPLICANTS: a permit does not authorize operation unless you comply with IZO Chapter 2-28 and all applicable regulations.
Mark location standards A to D
Mark an X in each box for standards A through D: zone, 2,300-foot separations, and the 500-foot separation from another sexually oriented business.
Mark standards E to L
Mark an X for parking, mobile structures or pushcarts, parking lot security system, signs, planning area design, zone design, traffic study and noise standards.
Mark operating conditions M to R
Mark an X for special events, prohibited services, display of materials, age limits, hours of operation and the criminal history standard in R.
Mark conditions S to X
Mark an X for the manager's station layout, lighting, individual viewing areas, restrooms, live entertainment setup and the gratuity rule.
Mark conditions Y to AA
Mark an X for no physical contact between performers and patrons, security guard requirements and the prohibition of public nudity.
Print name, sign and date
In AGREEMENT, enter your PRINT NAME, APPLICANT SIGNATURE and DATE. The signature certifies, under penalty of perjury, that the information is true and correct to the best of your knowledge and belief.
Leave the office-use block blank
Do not complete FOR OFFICE USE ONLY; the City fills in the recommendation, case number, planner and permit expiration date.
Review and download the completed PDF
Check that every box from A through AA is marked and the signature and date are entered. Download or print the completed PDF from FillingPDF and add it to the package described under How to submit.
How to submit 43-84
Submit Form 43-84 online through the City of Irvine's online submittal portal, together with the other forms in the package.
- Online portal: https://cityofirvine.gov/irvineready. The form instructs you to submit all forms, including this attestation form, there.
- Package contents: the completed development case application, developer deposit case setup form, electronic/digital signature disclosure (if actual signatures are not included on the application and deposit forms) and this attestation form.
- Fees: the City requires payment of the initial deposit fee amount listed in the Planning and Development Services Fee Schedule. The amount is not repeated here; check the fee schedule or ask the Planning Counter.
- Questions: Planning Counter, 949-724-6308 or [email protected].
The form names no mailing address or in-person channel. FillingPDF lets you fill out and download the PDF; submission follows the City's channels above.
Common mistakes to avoid
- Filing Form 43-84 on its own instead of with the Sexually Oriented Business Permit development case application (PSX), as the form requires.
- Leaving a box unmarked: the form asks for an X in each box to show agreement with all listed standards and conditions.
- Treating a permit as authority to open; the form says you must also comply with IZO Chapter 2-28 and all applicable regulations, and obtain a business license.
- Measuring separation around buildings; Standards B, C and D use a straight line from property line to property line, or door to door when on the same lot.
- Omitting the electronic/digital signature disclosure when actual signatures are not on the application and deposit forms.
- Submitting the form without printing a name, signing and dating the agreement.
- Writing in the FOR OFFICE USE ONLY block, which holds the Community Development recommendation, case number and permit expiration date.
Frequently asked questions
What is Form 43-84 in Irvine?
Form 43-84 is the City of Irvine's Sexually Oriented Business Attestation Form. Applicants mark an X for each location standard and operating condition and certify the information under penalty of perjury. It must be filed with the Sexually Oriented Business Permit development case application (PSX).
Is Form 43-84 an Irvine business license application?
No. The form says prospective operators must submit the development case application, deposit setup form, any signature disclosure and this attestation form, pay the initial deposit and also obtain a business license. For an Irvine business license, contact the City; this form does not provide one.
Where do I submit Form 43-84?
Submit it through the City of Irvine's online submittal portal at https://cityofirvine.gov/irvineready, together with all the other forms in the package. For questions, contact the Planning Counter at 949-724-6308 or [email protected].
What must I submit with Form 43-84?
The completed development case application (PSX), the developer deposit case setup form and, if actual signatures are not on those forms, the electronic/digital signature disclosure. You must also pay the initial deposit fee listed in the Planning and Development Services Fee Schedule.
How far must the business be from homes, schools and parks?
Standards B and C say at least 2,300 feet from residential zones and uses, religious institutions, public park facilities, child care centers and schools; standard D says 500 feet from another sexually oriented business. Distance is measured in a straight line between property lines.
Can I sign if I was found guilty of a sex-related offense?
Standard R requires that neither the applicant, nor any officer or general partner of a corporation or partnership, has been found guilty within the past two years of violating a similar permit or of a state-classified sex-related misdemeanor or felony, including the listed Penal Code sections.
What if my permit is denied or my business does not comply?
If the business is found not to comply with City requirements, the permit may be revoked under IZO Section 2-28-10. If your request is denied, the form says you are entitled to prompt judicial review under IZO Section 2-28-4(C).
Can I fill out Form 43-84 online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent of the City of Irvine and does not submit the form; you submit it through the City's online portal.
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