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City of Orono
Subdivision Exception Application
SlraatAddrass:
Applimlion #
2750 Way Parkway
Orono. MN 55356
Date Received:
Staff
Main: 952 249-4600
fax 952-2494516
Fee:
Ma&V A6*4=
Notes:
P.O. BOX 66
CrysW Bay. MN 55323.006E
SITE LOCATION(S): {)(A [ La7 _ V)&r�[S . 2-1„
PROPERTY OWNER 1 IN
Name: j
Phone (primary): _
Mailing Address: _
Email: _
PROPERTY OWNER 2 INFORMATION,
Name: /17.7ek 4 L
Phone (primary):
Mailing Address:
Emafl:
O.W
ZIP:
n - 14rld"1 G4 M dL'^'e'-
ZIP:
APPLICANT INFORMATION
Same as Property Owner 1 or Property Owner 2 (dreie one) above; Or
Name:
Phone (primary): ZIP.
Mailing Address:
Email:
• Certifies 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
atte nBe" but to reject it urrtg it is complete or to recommend the request for denial of the request regardless of its potential
merit.
• The Property 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.
41 Mfornu don will be distrbAed via
Property Owner 1 Signature: Suxe Yadd"A `Q
Property Owner 1 Signature: 1=
Property Owner 2 Signature: I
Property Owner 2 Signature: QA4120171,7:,a A, 1
211�20172:11'53 P►1 CST
ApplicantSignature: ' l-
Applicant Signature:
Subd&*bn ExcepWn App colon Packet— January 2017
Pape 2
12/1412017
Date:
Date:
Date:
Data: µ"!u It
Date: IL-9-17
Date:
Authentkign M
City of Orono
Vacation Application
Sfreel Address:
2750 Kelley Parkway
Orono, MN 55356
Main: 952 249.4600
fax. 952-2494616
Mailing Address:
P.O. Box 65
Crystal Bay. MN 55323-0056
Application #
Date
Received:
Staff :
Fee 0_0, '
Escrow.
Notes: Fees assume
application not part of
subdivision.
1 We request an Easement or Right of Way on/or adjacent to the following property be vacated:
PROPERTY INFORMATION:
Site Address: .3 a
Submittal Requirements
0
1
Completed Vacation Application
E3
2
Application fee
l)
3
Escrow deposit and egreement
0
4
Survey (meeting ALL requirements) Click here for the C' 's Survey and Site Plan Requirements.
0
5
Data eriva2y form
13
1 6
Hardcover Calculation worksheets. Click here for the Ci s Hardcover Information racket.
0
1 7
Additional Information requested b Cl Stan
8
1 Electronic co2y of all submitted materials via email, CD or flash drive.
PROPERTY OWNER INFORMATION:
Name: rVCa t
Phone (primary):
Mailing Address: 1 SO>�
City, State & ZIP a �;
Email:
legal names and marital status required for each interested party)
th✓aldpU- lyoo r,-w�e `s cc, 11146 c
• Certifies that the information suppled Is true and correct to the best of hislher knowledge. The applicant and owner recognize that
they are solely respar>sile 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 Property Owner hereby acknowledges and agrees to this applicatlon 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
• Property Owner adatowledge [hey must be present at all scheduled review meetings of the City Councal. If an ;ppplicanl andlor
owner is unable to attend a scheduled meeting, please make arrangements to have an authorized representative attend In place of
the applicantlowner and advise the City Planner assigned to y* project
Property Owner Signature: `.,t3Ku a gadded Date:
Property Owner Signature _-?„{Ap,7 ,cos s, P4r+»�e Date:
[ &ERE ywu� L11^44
71 t.{7:5{ PM CST 17114= 7 2:115e PM CST
Vacation AppHcatlon - Janualy MI
1211412017
Authenllslgn 1D 18iB
DATA PRIVACY ADVISORY
In accordance with Minnesota State Statute 13.04 Rights of SuNects 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.
Sry t c Pa-'0 v'Ic
First Middle Last
1500 ry &�:-e- ti5 Ppt,,�
Address
nn o /vt/ .-s' 3 q
State
Zip Phone
I understand my rights as stated above.
AU���r�G
iKL[CC ,� C g . C lC %�TevR%. M-41"
,. ,
Subdiviskn App►k-Wan — January 2017
Page 13