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-17 <br />j y /� of<d i✓a�Pt Veto <br />CITY OF MOUNDS VIEW .'. .. <br />APPLICATION 1,X 4;rd z x ' <br />Date <br />�• f y� S9 <br />LICAF f ` Name GP RGt l Q • ` (� %ir�C c <br />..3yy,, -Fnone� Q9 <br />c _.S'Addreae�o'S{S�Ed�e�iiooci''DP. <br />Interest in Property (check appropriate box): <br />Omer of Record Lessee, Operator, Ma%Rer . <br />Contractor for Deed Owner Agreement to Purchase <br />Other (Explain) : % `(3 - .444g ' <br />Documentary evidence of applicant's interest in the property may be reunited <br />before final City action on this tequest.�. <br />FROFER,^Y: - Address/Gederal Location 905(yg: 0 pa . <br />Legal Owner:. Fame/Address ���d j7; e�ddP�S i <br />on etc/ J i A <br />Present Use (Check Appropriate Box): <br />Undeveloped/Vacant - Apartment <br />Single Family Dvellinq Busiress Esablishment <br />Duplex Dwelling Industrial Establishment <br />Multiple Dwelling (3-6 units) <br />Other (explain) <br />Property Classification: Abstract Torrens <br />REOUF,STX <br />I hereby declare that the above statements are true ��!!F (!Ee-�d-av/ <br />(signature) - <br />FOR OFPICF. USE ONLY: <br />Subdivision, Maior <br />Subdivision, Minor <br />Roronira <br />Conditional Use <br />Variance <br />Code Appeal <br />Alteration Permit <br />Park Fund Dedication <br />Date Paid <br />Receipt Number <br />TOTAL <br />BASF, *(Base Fees are <br />Non -Refundable) <br />DEPOSIT <br />FEES <br />' <br />S250 <br />($150) <br />TOTAL FEES PI.ID <br />$100 <br />($75) <br />Date Paid <br />S100 <br />__ <br />($50) <br />Receipt Numher <br />S100 <br />(S50) o p..p <br />$ 75 <br />(S50) <br />S100 <br />(S50) <br />1150 <br />(S50) <br />