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Property Owner Information <br />(!f different than Applicant) <br />Name: <br />County of Anoka <br />Street Address: <br />2100 Third Avenue, STE 720 <br />City, State, ZIP: <br />Anoka Minnesota 55303 <br />Home Phone: <br />work Phone: <br />763-421-4760 <br />Email: <br />Fax Number: <br />Please provide a detailed description of your request and attached a copy of a scaled site plan <br />See attached Memorandum of Agreement between Anoka County and the City of Ramsey for Public Work <br />Improvements Related to the Ramsey Town Center Development, dated September 22, 2015 (Anoka County <br />Contract No. C00043:50) <br />A "Land Use Sign" will be placed on the Subject Property to allow Ramsey Residents the <br />opportunity to obtain information about your request. <br />Applicant Signature <br />Co -Applicant Signature <br />Printed Name <br />And`e�v J. Witter <br />Printed Name <br />Title <br />Assistant County Engineer <br />Title <br />Date <br />Date <br />I understand that the applicatidn fee is non-refundable. All costs associated with the processing of this application are the <br />responsibility of the applicant whether this application is approved or denied. Any excess of escrow account deposits over <br />expenditures will be refunded at the time of account closure. I also understand that as the applicant, it is my responsibility to obtain <br />all other permits or licenses required by any applicable regulatory agencies for this Land Use Application. <br />Property Owner <br />Signature <br />Property Owner <br />Signature <br />Printed Name <br />County of Anoka <br />Printed Name <br />Title <br />Title <br />Date <br />Date <br />I hereby certify that I am the fee title owner/contract for deed vendee of record for the above-mentioned property. Failure to prove <br />ownership may void any agreements entered into the City and I will be held liable for any and all costs incurred by the City. <br />City of Ramsey General Land Use Application Guide Version 1/1/2013 <br />