HomeMy WebLinkAboutApplicationCity o lrf
StmetAddress: Application # n
III 2750 Kelley Parkway --� L A I � _ tw
Orono. MN 55356 Received:
Staff — J - --- -- -
,, Main: 952-2494600
fax: 952-249-4616 Application Fee:
Fs'rs��`-` Mailing Address: ! Escrow. ;
- - - P.O. Box 66 _
i Crystal Bay, MN 55323-0066 j Notes:
PROPERTY INFORIitiATION-
Site Address:
Property Identification Number (PIN): 3 - 3 a —
Date Property Acquired (month/year): a Xf& %Abstract ❑ Torrens (Please check one)
Present use of property: Td'Residential: number of Units 1
0 Other (specify) _
Zoning District: _r!�- / A
APPLICANT INFORMATION: ❑ check here if Applicant address should be used for billing
Applicant:
Phone (Primary):
Mailing Address: i E- Q Cityl-� ZIPS: day
Email Lc: Iev hv'L.S. r.
PROPERTY OWNER OWNER INFORMATION: IJ check here if Property Owner is same as applicant
❑ check here if Property Owner address should be used for billing
Name:
Phone (Primary):
Mailing Address: City: ZIP:
Email:
EXISTING LAND USE:
Number of Tax Parcels:
Development Size: &L -IT Acres Dry Land
Acres Wet Land
, 2. Acres TOTAL, all parcels
PROPOSED LAND USE:
• Division for Tax Purposes
0 Subdivision for New Building Sites
Number of Building Sites:
Existing Units:
New Units: }
Total Units:
Proposed Gross Density Units per acres
Minimum Lot Size: _�,�_ �t dry buildable land
Proposed Use (check),kResidential f�
❑ Other (specify) _.
S
RECEIVED
APR G :-7 Z018
Subdivision Application - January 2017
Page 5 CITY OF ORONO
APPLICANTIAGENT AND/OR PROPERTY OWNER:
• Agree to provide all information required or requested by the Planning Department
e Agree to pay additional fees (staff time not covered in the original fee payment) and/or consultant expenses incurred in
review of this application, and
Certify that the information supplied is true and correct to the best of his/her knowledge. 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 hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property
by City Staff, consultants, agents, Commission and Council Members for purposes of investigation and verification of this
request
Applicant and/or Owner acknowledge they must be present at all scheduled review, meetings of the Planning Commission
and Council. If an applicant and/or owner is unable to attend a scheduled meeting, please make arrangements to have an
authorized representative attend in place of the applicantiowner and advise the City Planner assigned to your project.
Information will be distributed via email_
/Applicant Signature:
✓Applicant Signature:
f -
41 Property Owner Signature: !�'f
Property Owner Signature:
r�
Subdh4ston Appikafion — January 2017
Page 6
Date. Sk
Date: `f-� 10
Date:X/A-
Date:� s
a
DATA PRIVACY ADVISORY (Property Owner 1)
In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we
would like to inform you that your request for a permit or license from the City of Orono or any of its departments
may require you to furnish certain private or confidential information.
You are notified that:
1. The information you furnish will be used to determine your qualification for the permit or license
requested.
2. You may refuse to supply data, but refusal may require that the City deny the permit or license.
3. The information may be shared with other local, state or federal agencies to the extent necessary
to process the permit or license.
4. If your requested permit or license requires Council action to approve, some information may
become public.
5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review private
data on yourself.
6. Your full name is required to process this application or permit.
First Middle Last 7
�idll( tt _
{'ilGk'C
Address
City State Zip Phone
I understand my rights as stated above.
Signature
Subdivision Exception Application Packet — January 2017
Page 4
RECEIVED
APR G Z018
CITY OF ORONO