HomeMy WebLinkAbout16-3862 ExA APPCity of Orono
Conditional Use Permit Application
StreetAddress.Application #2750 Kelley Parkway
OOrono, MN 55356 Date Received:
Main: 2600 Staff
fax: 952-249-4649-4616 Fee:
Mailing address: Escrow # & $
P.O. Box 66
G Crystal Bay, MN 55323-0066 Permit Fee
Doti Notes:
Please complete. Applicant will be notified within 15 days as to the status of the application.
Incomplete applications will not be placed on Planning Commission Agendas.
SITE LOCATION:
APPLICANT / AGE
Applicant Name:
Phone (Primary):
Applicant Email: _
Address: _
Agent Name:
Agent Email:
INFORMATION:
6berIc-- L
VMS
PROPERTY OWNER INFORMATION:
Name:
Phone (Primary):
Mailing Address:
Email:
Agent's phone number
Applicant is: Contractor
ZIP:
Homeowner (Circle One)
Ycheck here if property owner is same as applicant
APPLICANTIAGENT AND/OR OWNER:
• Agree to provide all information required or requested by the Planning Department,
ZIP:
• 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.
• Acknowledge the Escrow Agreement is completed and signed.
• 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.
• Owner and/or Applicant acknowledge they must be present at a[I 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 applicant/owner and advise the City Planner
assigned to your project.
Applicant/Agent Si nature:
9 Date: `�-
Applicant/Agent Signature; Date:
Property Owner Signature: Date:
Property Owner Signature: Date: �'R�ECE IVEEE
CUP APPlication - January 2016
Page 2 3862
AUG 1 7'2016
CITY OF ORONO
DATA PRIVACY ADVISORY
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
Address
City
Last
State Zip
CUP Application - January 2016
Page 8 3862
Phone
9
RECEIVED
AUG 17 2016
CITY OF ORONO