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PLAN NI Iio hPPI :!JI CY Dute <br />phontQ,-A <br />APPLICANT: name _ SA <br />add:e:s 7.; <br />Interest In property (check appropriate Lox): <br />❑ owner of record ❑ lessee, operator, manager <br />❑ contract for deed owner 9/ agree"nt to purchase <br />❑ other (explain) <br />Documentary evidence of applicant's interest In the property may be <br />required before final city action on this 1e4Ve5t- <br />PNOPERTY: address/general location <br />legal owner: <br />rA <br />preuse (check appropriate box) <br />J Jndeveluped ® business establisMNmt <br />❑ singie Family dwellinq ❑ Industrial establishment <br />❑ duplex dwell'ng ❑ apartments <br />❑ other (explaic) <br />kEQUEST: (explain) <br />I hereby declare that the above statements are true. <br />FOR OFFICE USE ONLY: <br />BASE FEES" <br />subdivision, major ($1501 <br />subdivision, minur ($70 <br />rezoning ($So) <br />conditional use ($5t)) <br />variance ($50) <br />code aPpcal ($50) <br />5:btutal <br />*Base fees In parenthesis ere non- <br />refundable. <br />Park funJ dedication <br />date paid <br />receipt f <br />ADD,TIONAL FEES <br />reapportionment <br />public hearing notire5 <br />staff, consultant reviews TSB <br />subtotal <br />TOTAL FEES 0-12 <br />datt. paid <br />receipt Aj 9S6 <br />MT <br />