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'I'M E CITY OFLAKE ELMOLake Elmo City Hall651-747-39003800 Laverne Avenue NorthLake Elmo, MN 55042ACKNOWLEDGEMENT OF RESPONSIBILITYThis is to certify that I am making application for the described action by the City and that I am responsiblefor complying with all City requirements with regard to this request. This application should be processed inmy name and I am the party whom the City should contact regarding any matter pertaining to this application.I have read and understand the instructions supplied for processing this application. The documents and/orinformation I have submitted are true and correct to the best of my knowledge. I will keep myself informedof the deadlines for submission of material and of the progress of this application,understand that this application may be reviewed by City staff and consultants. I further understand thatadditional information, including, but not limited to, traffic analysis and expert testimony may be required forreview of this application, I agree to pay to the City upon demand, expenses, determined by the City, thatthe City incurs in reviewing this application and shall provide an escrow deposit to the City in an amount tobe determined by the City. Said expenses shall include, but are not limited to, staff time, engineering, legalexpenses and other consultant expenses.I agree to allow access by City personnel to the property for purposes of review of my application,<:^^/Signature of applicapt [ _^^f/L\^^ —^ Date \ (L""7A "ZQ^Z.Name of applicant Dominik Jensork_y _Phone 612-305-7095(Please Print)Name and address of Contact (if other than applicant) dJenson@sr-re.COm