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Fonn. <br />^ ^ofF^e^ Hennepin County Depaitment of Fmance. A ou <br />ir%t_. V U^tyAnwt fof SMT\C <br />2. <br />3. <br />df ^ ^ ’ '' ' <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />10. <br />Hennepin i.,ouniy - <br />^ ^InS of Suney (signed by a Uoenaed surveyor) - refer to handout for survey <br />information. «u..,,;nn if not included on required survey. <br />"'■ ------- you Wish notified of this application. <br />YOU ARE REQUIRED TO <br />bsns"wa.‘”;ui«" -cardrawinss of a), docutnents, p.ans, etc. to be <br />n r must sign this application. Please remember that your <br />uTTbove information has not been mcluded. <br />Cettification by Clerical Department dial Land Use^caUonJscom^_____________ <br />Initials of Clencal Staff.---------------------- <br />;».2 j;— <br />AdmiSLator. agrees >“ P^^'““l/r:/oiis application, and certifies that the information <br />Applicant ’s signature <br />owner ’s signature -------------- ' Meeting Planning <br />.„acanim»h.entw — <br />?;^3'S!l^gTp“«“-> -he <br />Date