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� ���y �f ���►r�o <br /> • �������'�� PC Exhibit A <br /> ������b��e �� <br /> Street Address: Applicatiort# � `'��� <br /> �.�o�,.0 2750 Keliey Parlcway Dete ReC�ivecl: <br /> �ronc,MN 55356 �n R- <br /> � Main: 852-2A�-4600 Staff: r�• rt/ <br /> fax: 952-249-4616 Fee: (,� " <br /> � 4 �i�' P.O�,Bwc�� EscfoW#&$ ' <br /> �` G� Cryatal Bay.MN 55323-0066 Pem�f!Fee <br /> {�k�s H O�'�' Notes: <br /> Please cornplete. Applicant will be notified within 15 days as to the status of the application. <br /> Incomplete appfications will�ot be placed on Pianning Comm[ssion Agenda. <br /> SITELOCATIfJN: 1"l�C� 'S�bY �illooY.� ��. <br /> QESCRPTION OF REQUEST: ��� L6C� �1 � _ � , 'U� <br /> {aft�ached additional sheets as nec�ssary) C.G�JL� <br /> APPLiCANT!AGENT 1NF4RMAT{ON: <br /> Applicant N�rr�e: � 1� <br /> Phone (Primary): <br /> Applioant Ema#: . <br /> Address: . C#t : ZIP: �I ( <br /> Applicant is: onVactar Homeowner �Circle ne� <br /> PROPERTY OWNER INFORMATtQN: ❑check here if property owner is sam as applicant <br /> Name: �� �3 <br /> �Phone(Primary): � - � <br /> �Maiting Address: d- Cit : ZIP: <br /> ?�maii: �r�?t��n.sinar:c:r�> Q.��c.t�►r�n-in�: t±o� M�i <br /> r <br /> APPLICANTIAGENT ANDlOR OWNER: <br /> o /�gree to provide all iniortnatlan requlred ar requested by the Pianning Department, <br /> + Agree to pay additional faes (ctaff time not covered in the ortg�nal fee payment) �ndlor cot�sultattt expenses i►ac�xred in <br /> revisw of this applioation,and <br /> • Certify that the informa�on suppfied Is true and correat to the hest of hts/l�er knowtedqe. The appllcant and awner <br /> recogMze that they are solely responaibte for submltEEng a complaba appitcatton beiag aware that upor�(allure to <br /> do sa�the staff has no altemative but to re}ect it untll ft is oomplete or to recomm�nd the r�queat for denial of the <br /> requQst regerdle6s o!Its potantial meri� <br /> • Adcnowledge ihe Escrow Agresmer►t is complet�d�+nd signed. <br /> 0 7he Owner hereby ackr�riedges and ag�es to tt�ts appiicadorl and further as�haizea reasonable entry onto the property <br /> by C�y Statf,caRsultBnt�,agerris,Canmisaion end Couna'�Members for purposes of investigatlon and veriticaUon of this <br /> request. <br /> • Owner andior Applicant acknowledge thay must be preser�t at all scheduled revEew meetin�s of the Planning <br /> Commisefon und Councii. If an applicaM and/or awner is unable tc attend a acheduled meeling, please make <br /> arrangementa to have an suthorized representative attend in place af the applicant/owner and advise the City Plannec <br /> asslgned to your project. <br /> Appl'tcanUAgent Signature: Oate: <br /> ApplicanU/�qent Signature: _ Date: <br /> � <br /> �C Property Owner Signature: Date: ���- •5��' - ���i_____ <br /> � Prope�r�'+Dwner Sfgnature: �� 5�� c�Pt� <br /> �: <br /> va.r�„�ap�euon—�ray zo�a p8�e a SEP 2 l 2016 <br /> �C!M OF ORONO � � $ 7� <br />