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Application fees are non-refundable. Present Use of Property R 5 S 1.12E NT 1 PrL-- Property Classification ,9 Abstract ❑ Torrens Description of Proposal (attach additional supporting documentation if necessary) r &u {e 4- Ur4 I ko 94fll FC r rho' it 4 Gr_), /1 k�e Tiid I '.711Ti' s,L ,F70Wra _ rd-.� BY MY/OUR SIGNATURE ON THIS APPLICATION, I HEREBY DECLARE THAT, TO THE i BEST OF MY KNOWLEDGE, THE INFORMATION PROVIDED IS TRUE AND ACCURATE. Eleggg Note: Application fees are nonrefundable. Applicants are responsible for all costs in excess of the application fee incurred by the City in the processing of this application. Such excess fees are to be paid upon receipt of statement from the City of Mounds View. Excess fees may include, but shall not be limited to, photocopy costs, staff time, and fees for planning consultants, attorneys and engineers. In some cases, a deposit may be required in advance to cover any anticipated excess costs associated with this application. (If a deposit is required, the applicant shall remain responsible for all reasonable incurred costs in excess of the application fee and deposit amount.) I ACKNOWLEDGE THAT I have read all of the information listed in the Planning Application and fully understand that I am responsible for all costs incurred by the City related to the processing of this application. Name of Applicant ( Signature of Applicz Name of Property Owner (typed/ Signature of Property Owner Address of Owner 13 LoPJF V& l Phone Number of Owner (o t2- 328- 2a5-7 E-mail of Owner -tyw d�� o its a� e�+K��,s'�. n tt Date of Submittal _ 60-day Limit Planning Case No(s) Application: Park Dedication: Deposits: Other: Total: Date of Acceptance: 120-day limit: Assigned to: (Fees Paid: Account # Ch Credit # Receipt # i01a 175p.it Page 2 of 2