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City of Orono Variance 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: Fee : Escrow# & $ Permit Fee Notes : PC ExhibitA Please complete. Applicant will be notified within 15 days as to the status of the application. Incomplete applications will not be placed on Planning Commission Agendas. SITE LOCATION: gacs 1:?(oL,0/\ Kc\. 0 Applicant Name : Phone (Primary): Applicant Email: Address : Applicant is: PROPERTY OWNER INFORMATION: jkl)check here if property owner is same as applicant Name: Phone (Primary): Mailing Address : Cit Email: APPLICANT/AGENT AND/OR OWNER: • Agree to provide all information required or requested by the Planning Department, ZIP: 5~5 l_p ZIP: • Agree to pay additional fees (staff time not covered in the original fee payment) and/or consultant expenses incurred in review of this application, and • Certify 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. • Acknowledge the Escrow Agreement is completed and signed . • 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. Variance Application -January 2016 Page 2 # 3812 RECEIVED flm 1~2 2®11