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C <br />Present Use of Property C3 2 0 � s 2 --"- <br />Property Classification ❑ Abstract <br />❑ Torrens <br />Description of Proposal (attach additional supporting documentation if necessary) <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 />Name of Applicant (typed/printed) <br />Signature of Applicant <br />Name of Property Owner (typed/printed) • —i I / RO U L , Ali 7Ut�sA <br />Signature of Property Owner <br />Address of Owner //2z 7 �n.) s 9 /%2 7���r7n c ✓� �U <br />Phone Number of Owner 612- <br />E -mail <br />/ZE-mail of Owner 3-` <br />✓N% /����i v1)A��/ �}z <br />FOR OFFICE USE ONLY: <br />Date of Submittal I I )U -- 16 Date of Acceptance: <br />60 -day Limit 01 - t 55 -1 In 120 -day limit: <br />Planning Case No(s) zc15 c7DI Assigned to: 6R1c°500 <br />Fees Paid: Account •#' <br />Application: 00 <br />Park Dedication: <br />Deposits: <br />Other: <br />Total: <br />Page 2 of 2 <br />Checic/Credit # Receipt # <br />