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Application fees are non-refundable. <br />SQoa 1•s <br />Present Use of Property �-rz <br />Property Classification <br />I'm <br />Ef Abstract <br />❑ Torrens <br />(attach additional supporting documentation if necessary) <br />C..., -.L. \,- k L„o c .,\.. le, `_ c,__ 0. Sncc..o " `Y:.�..o- oq7 Md3 aNC �4- W:\\ be_ <br />Please Note: Application fees are nonrefundable. Applicants are responsible for all costs in excessof the application fee incurred by <br />the City in the processing of this application. Such excess fees are to be paid upon receipt of statement from the Qty of Mounds <br />View. Excess fees may Include, but shall not be limited to, photocopy costs, 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 />application. (If a deposit is required, the applicant shall remain responsible for all reasonable Incurred costs in excess of the <br />application fee and deposit amount.) <br />I ACKNOWLEDGE THAT I have read all of the information listed in the Planning Appilcation and fully understand that am responsible <br />for all co incurred LIy e City related to the processing of this application. <br />AipipDht 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 Applicant (typed/printe) trzv r F�r� 1ve ya.� <br />Signature of Applicant <br />Name of Property Owner ( ped/pri ed) K2�:N \kt�\vz so <br />Signature of Property Ownerx-t���� <br />Address of Owner <br />Phone Number of Owner (0 Z /G (� <br />E-mail of Owner <br />FOR OFFICE USE ONLY <br />Date of Submittal 3 -3 - a `� Date of Acceptance: <br />60 -day limit 120 -day limit: <br />Planning Case No(s) Cu Aoa9 -ao / Assigned to: <br />Fees Paid: <br />Application: d15 3? 5 •00 <br />Park Dedication: <br />Deposits: <br />Other: <br />Total: <br />Account # Check # Receipt # <br />06 --5A 1 Lz-35-�;— <br />Page 2 of 2 <br />