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City of Orono Variance Approval Extension Application Street Address: 2750 Kelley Parkway Orono, MN 55356 Appli ca tion # Date Received : Staff: 1st Extension : administrative a roval Main: 952-249-4600 fax: 952-249-4616 Mailing Address: P.O. Box 66 2n d & Subsequent Extensions: $350 Crystal Bay, MN 55323-0066 (Council approval) This extension application form must be completed in full and submitted at least 60 days prior to the variance expiration. PROPERTY INFORMATION: ~ ~ Site Address: 3c!sci:5">4-Y5/.<:?e" ~ OWNER INFORMATION: (Complete legal names and marital status required for each interested party) Name: _/4:,IM) &,~ '?;wb-S$€ ,,,,Wo ~~ ?d-e~ Phone (home): ~LUZQ_ ~ ~ Phone (work): Complete Address: ~ ~~~ City, State & ZIP O~e, L1'/AJ ~ Email: i dt ~ss c:~ sceo;,,;,;zt;,?4 • o:;w,,--F-a-x: ___________ _ \/ / OWNER: • Agrees to pay additional fees (staff time not cove re d in th e original fee payment) and /o r co nsulta nt expenses i ncurred in review of this extension application, and • Certifies that the informat ion s uppli e d is true and correct to the best of his/her knowledg e. The applicant and owner recognize that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete or to recommend the request for denial of the request regardless of its potential merit. • The Owner here by acknowledg es a nd ag rees to thi s application and furth er a uthori zes rea sonable entry on to the property by City Staff, consultants, agents, Commission and Council Members for purposes of investig atio n and verification of this requ est. • Applicant and/or Owner acknowledge they must be present at all scheduled review meetings of the City Council. If an ap plican t and/or owner is unable to attend a schedu led meeting, please make arrangements to hav e an authorized representative attend in place of the applicanU owner and advise the City Pl ann er assigned to your project. • Some or all of the inform ation that you are as ked to provide on thi s applicati on is classified by Stat e law as eith er pri vate or co nfid ential. Private data is information which generally cannot be given to the public but can be given to the subject of th e data. Confidential data is information which generall y can not be given to either the public o r t he subject of the data. Our purpose and in tend ed use of thi s inform ation is to an nu all y update our records and records of other governmental agencies requ ired by la w. If you refuse to supply th e inform a ti on, the application may not be issu ed . Owner S ig natu re: D ate: Owner Signature: Date: