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<br /> <br />Dated: _____________, 20__. ___________________________________ <br /> _______________________ <br /> _______________________ <br /> <br />} SS. <br />STATE OF MINNESOTA <br /> <br />COUNTY OF ____________ <br /> <br /> <br /> On this ____ day of ___________, 20__, before me, a Notary Public within and <br />for said County, personally appeared _________________, __________________, to me <br />known as the person described in and who executed the foregoing instrument, who stated <br />that they are the owners of the property this permit applies to, and acknowledged that they <br />executed the same as their free act and deed. <br /> <br /> ______________________________ <br /> Notary Public <br /> <br />