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Application fees are non-relfundableo <br />Present Use of property <br />Property Classification <br />Co'n'n -i fV v (f h. C.4 <br />❑ Abstract <br />R Torrens <br />Description of proposal (attach additional supporting documentation If necessary) ^ S a A <br />Wow/r/ I. -A, /' re*0/..ce ow/ cuppen-/- .syn &,;A 4 r%y.. "c 4(,(14V <br />/'ke do ^egars{ c. ✓w�ranca A. <br />fo itg6/r (- rrfr ca/o/` & {dr L¢'O s, <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. <br />y <br />Name of Applicant(typed/printed) /(Ko"l <br />Signature of Applicant kz— <br />Name of Property Owner (typed/printed) <br />Signature of Property Owner <br />Address of Owner <br />Phone Number of Owner F V <br />E-mail of Owner kev 4/ .Jr (2Msll, cv.. <br />FOR OFFICE USE ONLY: <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 />