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,., City of Orono Variance Approval Extension Application Street Address: 2750 Kelley Parkway Orono, MN 55356 Main : 952-249-4600 fax : 952-249-4616 Mailing Address: P.O. Box 66 Crystal Bay, MN 55323-0066 Application # Date Received: Staff: 151 Extension: $50 2nd & Subsequent Extensions: administrative a roval $350 (Council approval) This extension application form must be completed in full and submitted at least 60 days prior to the variance expiration. PROPERTY INFORMATION: 79 ~/J I) A.\.. SiteAddress: · 0 /V ,.A.t...:>t,v/11 /,,(.0 no OWNER INFORMATION: (Complete legal names and marital status required for each interested party) Name: .:;;r;;;,N 'V. ...fi-AV•S Phone (home): & f z -? '2. S" -z ~ g S-Phone (work): CompleteAddress : 72'-o /V. 8'2,ow,.,, f2,:,k-b City, State & ZIP i....-=-N--f.:. LA\l.E MN Email: .::J""S.,-A\11 S @ CAM-tJ. alt ,£2S:l. Fax: 1,,2. -t 0-2-01/l OWNER: • Agrees to pay additional fees (staff time not covered in the original fee payment) and/or consultant expenses incurred in review of this extension application, and • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete or to recommend the request for denial of the request regardless of its potential merit. • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by City Staff, consultants, agents, Commission and Council Members for purposes of investigation and verification of this request. • Applicant and/or Owner acknowledge they must be present at all scheduled review meetings of the City Council. If an applicant and/or owner is unable to attend a scheduled meeting, please make arrangements to have an authorized representative attend in place of the applicanUowner and advise the City Planner assigned to your project. ' • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data . Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information, the application may not be issued. Owner Signature: Date: Owner Signature: Date: