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AppRation foes are non-refundaNe. <br />Present Use of Property <br />Property Classification <br />CoN'i /•1 w/II i�N �"'�^�'G� <br />❑ Abstract <br />(� Torrens <br />Description of Proposal (attach additional supporting documentation If necessary) I�115510- <br />/',Ee f re/o/ce pwi 4uPrc44- Syti w:/A4 wnwti:c �'r//wy <br />Wr w /✓ /'k Jo '< !n dpi. r..s� /oe.>t'•-� ...✓ <br />ejFd <br />BY MY/OUR SIGNATURE ON THIS APPLICATION, I HEREBY DECLARE THAT, TO THE <br />BEST OF MY KNOWLEDGE, THE INFORMATION PROVIDED IS TRUE AND ACCURATE. <br />Please Note: Application fees are nonrefundable. Applicants are responsible for all <br />costs in excess of the application fee incurred by the City in the processing of this <br />application. Such excess fees are to be paid upon receipt of statement from the City of <br />Mounds View. Excess fees may include, but shall not be limited to, photocopy costs, <br />staff time, and fees for planning consultants, attorneys and engineers. In some cases, a <br />deposit may be required in advance to cover any anticipated excess costs associated <br />with this application. (If a deposit is required, the applicant shall remain responsible for <br />all reasonable incurred costs in excess of the application fee and deposit amount.) <br />I ACKNOWLEDGE THAT I have read all of the information listed in the Planning <br />Application and fully understand that I am responsible for all costs incurred by the City <br />related to the processing of this application. l/t� <br />Name of Applicant(typed/printed) (u/�P l oltlf �Sej p`�t�O' <br />Signature of Applicant /�— <br />Name of Property Owner (typed/printed) <br />Signature of Property Owner <br />Address of Owner <br />Phone Number of Owner -76..- -791 y <br />E-mail of Owner ocev kA. . (2�s'a cra.� <br />.Y: <br />Date of Submittal <br />60 -day Limit <br />Planning Case No <br />Fees Paid: <br />Application: <br />Park Dedication: <br />Deposits: <br />Other: <br />Total: <br />Date of Acceptance: <br />120 -day limit: <br />Assigned to: <br />Account # Check/Credit # Receipt # <br />Page 2 of 2 <br />