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, <br /> PC Exhibit A <br /> . <br /> City of C�rono <br /> Land Use Permit Application <br /> Street Address: <br /> �O A r 2750 Kelley Parkway Application# �`p — 3 �� <br /> 1��O Orono,MN 55356 Date Re{;elVed: / — <br /> Main: 952-249-4600 Staff: m <br /> � fax: 952-248-4616 Fee: `��, d� <br /> � Mailing Address: E8CtOw#&$ <br /> y�, :; �' �C�' P.O.Box 66 <br /> G� Crystal Bay,MN 55323-OOtiG Pem11t Fee <br /> 1�KF s H 0�'� Notes: <br /> Please complete. Applicant will be not�ed within 15 days as to the status of the application. <br /> Incomplete applications will not be placed on Planning Commission Agendas. <br /> /� /► r <br /> SITE LOCATION: �v (�f�S�V�e r.✓ �V� �Q �q � 1 u vf � �f f f c��`/'c�"t � <br /> '���APPLICANT I AGENT lNFORMATIO • ,, !_ ,� (r � - <br /> Applicant Name: ____�__�_ � - �t�LS L-2-Gti�-✓ <br /> Phone(Primary): a — �-�. — t 3 � <br /> Applicant Email: • �-� c� �� , �.g,,,,.,��� <br /> Address: _ �2 r'ts �,'e �,.� �t City:�j,zTvt O ZIp: �S 3 S� <br /> Agent Name: .i//`r Agent's phone number � <br /> Agerrt Email: Applicant is: Contractor omeown (Circle One) <br /> PROPERTY OWNER INFORMATION:,�chedc here if property awner Is same as applicant'Y <br /> Name: =;J�;� ,_L_ �� <br /> Phone(Primary): — �r, �cv � <br /> Mailing Address: L_..en,t_�- L.,��� !'yj+U �� City: . ZIP� __ <br /> Email: � <br /> APPLICAN7IAGENT ANDIOR OWNER: <br /> • Agree to provide all inforrnation required or requested by the Planning pepartment, <br /> • Agree to pay additional fees {staff time not covered In the original fee payment) and/or consuRant expenses incurred in <br /> review of thls appllcation, and <br /> • Certify that the information supplied is true and corred to the best of his/her knowledge. The applic�nt and owner <br /> recogn�¢e that they are solely responslble for submltting a complebe appllcation being aware that upon fallure to <br /> do ao,the staff has no altemative but to reJect it untif it is complete or to recommend tha request for danlal of the <br /> request regardless of its potential merlt. <br /> • Adcnowledge the Escrow Agreement Es completad and signed. <br /> • The Ov►mer hereby acknowledges and agrees to this appfication and further authorizes reasonable entry onto the property <br /> by City Staff, consultants, agents, Commfsslon and Council Members for purposes of inves6gation and verificatlo�of this <br /> request. <br /> • Owner andlor Applicant acknowledge they muat be present at all scheduled revlew meetings of the Planning <br /> Commisslon and Council. If an applicent and/or owner is unable to attend a scheduled meeting, pleese make <br /> arrengements to have an autho' d representative attend in plaoe of the eppllcant/owner and advise the City Planner <br /> assigned to your projed. <br /> �' � l <br /> Applicant/Agent Signature: � �� d � Date: � � � <br /> Applicant/Agent Signature: Date: <br /> Property Owner Signature: ��[ 7j/L' G�t��w( Date: ( '� � � � � �D <br /> Property Owner Signature: Date: <br /> Lend Use ApplTcatlon—May 2016 <br /> PB�e 2 <br /> 7�' ,/ V � � SEP � � jOs� <br /> Cl�l(OF ORONO <br />