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City of Mounds View, YIN <br />Development Application <br />Present Use of Property <br />D Undeveloped/Vacant X Single Family Dwelling , <br />O Duplex/Two Family Dwelling a Multi - family Dwelling <br />a Business/Commercial Establishment 0 Industrial Establishment <br />O Other (explain) <br />Property Classification o Abstract 0 Torrens <br />Descr iption of Proposal <br />Page 2 <br />BY MY (OUR) SIGNATURE ON THIS APPLICATION, I HEREBY DECLARE THAT, TO THE BEST OF MY <br />KNOWLEDGE, THE INFORMATION PROVIDED IS, TRUE AND ACCURATE. r1 . <br />Signature of Applicant <br />Name of Applicant (typed/printed) <br />Signature of Property Owner <br />dk <br />fog z7r <br />Name ofProperry Owner ( typed/primed) 774 PIA rl,t~1 WC Lr Nl (= itjvt <br />Address of Owner ( \ tr k 1 <br />Phone Number of Owner lam\ .® ip 1a — tis. i aa f n E .`} <br />Date of Submittal <br />Date of Acceptance <br />Planning Case No. <br />Application: <br />Park Dedication: <br />Deposits: <br />FOR OFFICE USE ONLY <br />60-dav Limit <br />Assigned to: <br />120 -day limit <br />Fees Paid: Account Check # Receipt # <br />Other: <br />Total: <br />IY:I D ATAIG R O UPSIC O M D E V I FO R M SM E V AP P. FO R <br />1/98 <br />