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<br />2401 Mounds View Boulevard – Mounds View, MN 55112 <br />(763) 717-4000 - info@moundsviewmn.org <br /> <br />Application Date: VACANT BUILDING REGISTRATION $1,000 <br /> <br />Vacant Building Address: PID #: <br />Owner(s): <br /> <br />Attach additional sheets if necessary <br />Full Name (PRINT): <br />Company Name: <br />Street Address: <br />City: State: Zip: <br />Phone: Cell: <br />Email Address: <br />Lien Holder(s) or Others w/ <br />Legal Interest in Property: <br />Attach additional sheets if necessary <br />Full Name (PRINT): <br />Company Name: <br />Street Address: <br />City: State: Zip: <br />Phone: Cell: <br />Email Address: <br />Responsible Party: <br /> <br />Can be a Realtor©, leasing agent, <br />management company, mortgagor or <br />other party with direct or indirect <br />control or authority over the building. <br /> <br />Attach additional sheets if necessary. <br />Full Name (PRINT): <br />Company Name: <br />Street Address: <br />City: State: Zip: <br />Phone: Cell: <br />Email Address: <br />Relationship to Owner/Lien Holder: <br />Date building became vacant: Property Plan Attached or Must be Submitted by: <br />(within 30 days of Application Date) <br />Acknowledgement of Responsibility: The undersigned owner/agent: 1) avows and acknowledges that the information herein is complete <br />and accurate; 2) assumes responsibility for maintaining and securing the subject building in conformity with Mounds View City Code <br />Section 435 and other applicable codes; and 3) acknowledges the responsibility to notify the city in writing within 30 days of any <br />changes to information contained in this registration form. <br /> <br />Owner or Agent: Signature: <br />(Please Print Name)