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�it�► �f �a-o�� <br /> PC ExhibltA <br /> �t�r�c���ion�t l�se Permi� App1���tian <br /> �,�� �,�: _ <br /> 2750 Kelley Pa�icway APi�CBt{Ort# I � <br /> � . �} Orono,A�Y+!55368 �dte Ft�ed: <br /> U <br /> Ma�,: ��,� Sr��r: # G <br /> +� �.��,e ��: <br /> •� Ma►Nrg Aaobess: Esc,vw#8 g b <br /> '}'�, ti� PA.Box 68 <br /> ! �' Cryatal8ey.6AN 55323-0066 Pem�it Fes <br /> �kFS H O�'� <br /> N�es: <br /> Please camplefe. ApplEcarrt will be notified within 15 days as to the status of the appiicetian. <br /> Incomplets epplicat�ona will no!be p1ac.�d on Planning Commission Agendsa. <br /> St'fE LOCATION: ��I G� �1�� j� �(j �. �/� ��-ll�r��• �r_'�3 r <br /> APPLICANT 1 AGENT INFORMATION; ""—' <br /> Applicarrt Name: " /YE u � K�'v r,�,� <br /> Phone(Primary}: ��zz u a, � ��, . <br /> Applicant Emaii: , ,. � - . _ <br /> Acfdress: � � - � : ,�, <br /> n�er,t r�ame: z►P: 3 � <br /> Agent Emafl: �19ent's phone number <br /> APa�nt is: Contractar Hameowner (Circlf One) <br /> PROPER7Y OWNER iNFORMATtON: ❑ here e ropert�r owner is same as applicant <br /> Name: ��'. <br /> Phone(Primary}; • <br /> Mailing Address: ( �ti � CI . , <br /> EfTlaff: r ZIP: <br /> APPLICANT/AGENT ANDIOR OWNER: <br /> � Agree to provide aU informatlon requfred or requestea by the PlanNn9 Departrr►ant, <br /> • A�ree to pay aeidlUonal fiees(8iaff tlme not coverad in tfis origmal fae fraY►nerrtj and/or oonsu�ant ezpen�es incurred� <br /> review of thls ePPNcatipn,and <br /> • Certify that the informadon supplled fs true and c�rrrrect to tha best�f hisR�er knowled appltca�rt and oMmer <br /> roco�nae that they are sdelY responsibie tor sabmltttnq a cflrry�lete 9e. Tha <br /> da so.tf�e s�f f�e no altsrnxtiva bnt to n aPPti�daf being�nraro tf�at upon faflure to <br /> r'aqvest rsAardl�es of ks 1��t untFl it is comple�e or to rocortsm�nd the raquest ior d�nla!of tbe <br /> polentlal marit <br /> • Adulowledge fha Escrow AgBemeM re complebad and�igned. <br /> ' bY��h consu���nd agrees Lo fhls apptfc�tfon and Turther auUwrizea reasonable enhy onto the prope►iY <br /> age►tfs.Corr+miasbn end Courxal Membsrs for p�����e�y���� <br /> request. <br /> � Owrwr andlor Appllcant admawledge they muet be pr�ec�r►t at al! scf»duled reylew <br /> Commission and Councll If an applk:atrt endlor au�ner ie unable to ei�end a sc�iedul�� of tha Plaru�ing <br /> errangemerlta tQ have an autharized re attend fn of the epplic.arrt/avmar end ad�theP� make <br /> assi$ned bo Yuur Prolect GtY Plar►ner <br /> Applicant/A�ent Signature: Date: / �rU -.�l�j <br /> Applicat�tlAgent Signature: _Da#e: <br /> Property Owner Signatur Date: �l - Q�(� <br /> Property Qwner Signatune• r' Date: i <br /> �"P"°��°"�.�""eryz°'e RECEIVED <br /> Pepe 2 <br /> APR z o z��s <br /> # � $ �8 cnv o�oRONo <br />