Agenda - Council - 06/13/2017 - Laserfiche WebLink

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I Name: Street Address: (10s7 ,2 E_i-(,\��, ,jar City, State, ZIP: l io—v' Nl iki \\S r, it'd. ti352 Home Phone: �Il �.—�85—s4 Op Work Phone: Email: ,lax,iwc,10 A:‘ @ etn eazcQ Fax Number: -1r11-nCvoIA 4 Co01 Property Owner Information (If different than Applicant) t\\4ov\ci\ c...D1S" WC_ Sc --s9 bC 4'6a-- (0-14 -S9 4(.0 Please provide a detailed description of your request and attached a copy of a scaled site plan A "Land Use Sign" will be placed on the Subject Property to allow Ramsey Residents the opportunity to obtain infor►nation about your request. Applicant Signature Printed Name Title Date Co -Applicant Signature Printed Name Title Date 1 understand that the application fee is non-refundable. All costs associated with the processing of this application are the responsibility of the applicant whether this application is approved or denied. Any excess of escrow account deposits over expenditures will be refunded at the time of account closure. I also understand that as the applicant, it is my responsibility to obtain all other permits or licenses required by any applicable regulatory agencies for this Land Use Application. Property Owner Property Owner Signature e Signature Printed Name c_ID Lit-t:-J ¢►3 ki Printed Name Nolr`a LraaLreV1• Title C `e a Title C O 5 /;►J/_)- Date OS-iil-2a1'1 Date I hereby certify that I am the fee title owner/contract for deed vendee of record for the above -mentioned property. Failure to prove ownership may void any agreements entered Into the City and I will be held liable for any and all costs Incurred by the City.