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Jan 27 09 05:38p Wagstaff Management <br />559-582-4910 p.3 <br />Application fees are non-refundable. <br />Present Use of Property -ISF O� <br />Property Classification ❑ Abstract <br />❑ To rrens <br />Description of Proposal (attach additional supporting documentation if necessary) <br />Please Nate: Application feces are nonrefundable. Applicants are responsible for all costs in erress o. the application fee inured by <br />the Oty in the processing of this applicaCon_ Sunt excess fes are to be paid upon receipt of tatement from the City of Mounds <br />View. Excess fees may include, but shall not be limited to, photocopy cows, staff time, and fees for planning consultants, attorneys <br />and engineers In some cases, a deposit may be required in advance to cover any anticipated excess costs associated with this <br />aapliation. (If a deposit is required, the applicant shall remain esponsible for all reasonable incurred mss it excess of the <br />application fee and deposit amount) <br />I ACKNOWLEDGE THAT 1 have read all of the information listed in the Planning Applica`on and fully understand that I am responsible <br />far all costs incurred by the Ci eia:ed to the processing of this application. CD <br />Aopricant /` Date <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 />Name of App <br />x Signature of. <br />Name of Prof <br />Y Signature of <br />/ Address of 0 <br />Phone Numb <br />E-mail of OW <br />#zxxf-'X#%##�k*#*+K#1###•F#*x*###X�k*#*#�sx#x**:kMt*#ie>k###�aK#Y*c**.K*#�k#�'#*#*t*,k###z###�Y ##X#3� <br />FOR OFFICE USE ONLY <br />Date of Submittal .i - 9 - n !f Date of Acceptance: <br />60 -day Limit 120 -day limit: <br />Planning Case No(s) 1,4kl u D -dG I Assigned to: <br />Application: <br />Park Dedication: <br />Deposits: <br />Other: <br />Total: <br />Fees Paid: Account # Check # Receipt # <br />315•,6 Flo -Acid JA-IIA3S <br />Pie 2 of <br />