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City of Orono <br />Land Use Permit Application <br />Street Address. Application # <br />Orono, <br />Kelley Parkway <br />Orono, MN 55356 Date Received: 0 2-0 j <br />Main: 952-249-4600 <br />Staff <br />fax: 952-249-4616 Fee: <br />~a„ Mailing Address. Escrow # & $ <br />P.O. Box 66 <br />G� Crystal Bay, MN 55323-0066 Permit Fee <br />SES HO�� Notes: <br />Please complete. Applicant will be notified within 15 days as to the status of the application. <br />Incomplete applications will not be placed on Planning Commission Agendas. <br />SITE LOCATION: {V215 TIM% t" "DKZ_t 't f�ft <br />APPLICANT 1 AGENT INFORMATION: <br />Applicant Name: MkVT QtAt 'C" <br />Phone (Primary): Ol 2- ES 1 - "-1 52 <br />Applicant Email: i L . <br />Address: ?F�L�E "�iLtV� _ City: <br />Agent Name: Agent's phone number <br />0 ZIP: X356 <br />Agent Email: - Applicant is: ContractorHomeowner (Circle One) <br />PROPERTY OWNER INFORMATION: check here if properly owner is same as applicant <br />Name: <br />Phone (Primary): <br />Mailing Address: City: ZIP: <br />Email: <br />APPLICANTIAGENT AND/OR OWNER: <br />• Agree to provide all information required or requested by the Planning Department, <br />• Agree to pay additional fees (staff time not covered in the original fee payment) and/or consultant expenses incurred in <br />review of this application, and <br />Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner <br />recognize that they are solely responsible for submitting a complete application being aware that upon failure to <br />do so, the staff has no alternative but to reject it until it is complete or to recommend the request for denial of the <br />request regardless of its potential merit. <br />0 Acknowledge the Escrow Agreement is completed and signed. <br />The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property <br />by City Staff, consultants, agents, Commission and Council Members for purposes of investigation and verification of this <br />request. <br />• Owner and/or Applicant acknowledge they must be present at all scheduled review meetings of the Planning <br />Commission and Council. If an applicant and/or owner is unable to attend a scheduled meeting, please make <br />arrangements to have an authorized representative attend in place of the applicart/owner and advise the City Planner <br />assigned to your project. <br />Applicant/Agent <br />Applicant/Agent <br />Property Owner <br />Property Owner <br />Land Use Application - may zu7a <br />Page 2 <br />•7 I—t <br />RECEIVED <br />JUL 2 0 7016 <br />3853 CITY OF ORONO <br />