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3124125, 2:01 PM <br />Revize Online Forms <br />Chicken/Duck Keeping License Application <br />FDel] <br />Submitted by: Ana Concepcion Rivera Parra <br />Submitted On: 2025-03-24 13:54:48 <br />Submission IP: 199.249.109.13 (172.31.71.138) <br />proxy-IP (raw-IP) <br />Status: Open <br />Priority: Normal <br />Assigned To: Barb Benesch <br />Due Date: Open <br />mou__]_�MslVitv <br />ANNUAL CHICKEN/DUCK-KEEPING <br />Valid from January 1 — December 31 <br />LICENSE APPLICATION <br />2401 Mounds View Blvd. I Mounds View, MN 55112 <br />(763) 717-4000 1 Fax (763) 717-4019 <br />info@ m o u n d svi ewm n.org <br />Requirements relating to the keeping of chickens and ducks is located in Mounds View City Code Chapter 90.005. All permit holders are <br />required to be familiar with the provisions of this chapter. In submitting a license application, the applicant declares that they meet the <br />requirements for issue of said permit, and that such location will be operated in compliance with the adopted regulations and <br />ordinances. All chicken & duck keeping licenses are valid from January 1 through December 31 of each year. The application fee will not be <br />pro -rated and is non-refundable. <br />0 New Application $100 (Site Plan Required) <br />❑ Renewal Application $30 <br />* Applicant First Name <br />Ana Concepcion <br />Street Address <br />8478 long lake <br />Phone 1 <br />* Applicant Last Name <br />Rivera Parra <br />0 Chickens # of Chickens <br />❑ Ducks 10 <br />k Email <br />Valid Email {required <br />City <br />moundsview <br />Phone 2 <br />Ex. (123) 456-7890 <br />State <br />mn <br />If the applicant is not the owner of the property, please complete the section below: <br />Owner Name <br />Phone 1 <br />Ex. (123) 456-7890 <br />Street Address <br />City <br />Email <br />Valid Email Required <br /># of Ducks <br />2 <br />Zip Code <br />55112 <br />State <br />Zip <br />PRIVACY NOTICE: I understand the information provided in this form may be considered private or confidential data. I further understand that I may not be required by law to provide <br />such information. The purpose of providing such information is to aid the City in its determination on said application. I acknowledge that providing, or failing to provide, such <br />information may affect the City`s determination on said application. I understand this information will be made available to the City of Mounds View, its City Council, agents and <br />https-llmoundsvlewmn_rja. revize-cum Ire ports1777348 112 <br />