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;rmanent Non-Multiple Dock License Applica <br />4. Site lake frontage: (aoo 1 feet; distance of dock into the lake: 5D I feet. <br />5. All setbacks for the dock use area have been observed 6() yes ( ) no. <br />6. All required pennits, licenses and approvals have been obtained from the city in which the <br />permanent dock is located, and from the DNR: ( ) yes ( ) no <br />Explain:------"'=------------------------ <br />7. Application Fee ........................................ $ 150.00 <br />After-the-fact application fee .................... $150.00 <br />Total Fee enclosed ......................................... $ __ _ <br />I certify that the infonnation provided herein and the attachments hereto are true and correct; I <br />understand that any license issued may be revoked by the District for violation of the LMCD <br />Code. I agree to reimburse the District for any legal, surveying, engineering, inspection, <br />maintenance or other expenses incurred by the District in excess of the am~unt of the <br />application f~e. I consent to pennitting officers and agents of the District to enter the premises <br />at all reasonable times to investigate and to detennine whether or not the Code of the District is <br />being complied with. <br />I agree to submit a certified, as-built survey upon completion of the docks. <br />~ -/-S:0,) <br />Autbor:ignature Date <br />Ce f\ i'., c~ \ fi'lcw\G5-e, <br />Title <br />Ca i\1,,-c<!/lo t' <br />Relationship to Owner <br />Return this application, attachments and fee to: <br />Lake Minnetonka Conservation District <br />18338 Minnetonka Blvd. <br />Deephaven,'MN 55391.:.3232 <br />Fax: (952) 745-9085 <br />2 of2 <br />JAN -7 2005