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• <br /> PC <br /> Exhibit A <br /> City of Orono #17-3889 <br /> Variance Application <br /> Street Address: Application# /7-38'467 9 <br /> ASLO/,0 2750 Kelley Parkway <br /> Y Orono,MN 55356 Date Received: /oi-/}'/k <br /> Staff: <br /> Main: 952-2494600 ,y <br /> fax: 952-249-4616 Fee: , <br /> It 4. P.O.Mailing <br /> 68 ss: Escrow#&$ ,���� ,' <br /> G� Crystal Bay,MN 55323-0066 Permit Fee j I <br /> t40$H01- 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 Agenda. <br /> SITE LOCATION: ) Ill 0 ?V-sSFec-:::t' AA_ W} t7(�, <br /> -1 <br /> 41 <br /> DESCRPTION OF REQUEST: C&`., IOIWQP 24aQUOS <br /> (attached additional sheets as necessary) <br /> APPLICANT I AGENT INFORMATION: pl <br /> Applicant Name: }} �(j f>, <br /> Phone(Primary): C1 - 4''1e 6L.64 <br /> Applicant Email: <br /> Address: % c �1�A .1g C4c )ca. City: alb, 5684 ZIP: <br /> Applicant is: Contractor Homeowne (Circle One) <br /> PROPERTY OWNER INFORMATION: 0 ch if property owner is same as applicant <br /> Name: - .. YV <br /> Phone(Primary): (, S� - <br /> Mailing Address: A `ex c ick rz A,, City: 56 I ZIP: <br /> Email: JG,,c d',t - .(`C akk 1 C_+Om <br /> APPLICANT/AGENT 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 /> • 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 applicant/owner and advise the City Planner <br /> assigned to your project. <br /> Applicant/Agent Signature: Date: <br /> Nall , <br /> Applicant/Agent Signature: \lam ift Date: 1 A*\.\10 <br /> Property Owner Signature: - �_"s — Date: c9-I JO1 1 k <br /> Property Owner Signature: Date: <br /> RtcE1VED <br /> Variance Application—May 2016 <br /> Page 2 DEC 147_01R <br /> 3889 MY OF ORONO <br />