Agenda - Council - 01/08/2019 - Laserfiche WebLink

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Property Owner Information (If different than Applicant) Name: ,- A / ` / C Street Address: City, State, ZIP: Home Phone: Work Phone: Email: Fax Number: Please provide a detailed description of your request and attached a copy of a scaled site plan 3/)!a-/I L n r Ati x // o CO S I/ 8 /e/ zs ef1/i(wi ��1- �m8 A SS. �r- is I on/4,4ed Nc V f 0 tiev ,e4 j (9s5 A c c'S /%, /gtp a 1/6)02,, U,'c?uld I (eke ''+0 /4 e-r e le =/- /4 L''o 4- Fify/r��/ey, 2c 1t Its __ 1� /34_e.12 sty,-t 11-k 8000 Ooo s� l=ee s or✓' / 7`i1Cc c Li Pc A "Land Use Sign" will be placed on the Subject Property to allow Ramsey Residents the opportunity to obtain information about your request. Applicant Signature //ii Co Applicant Signature Printed Name 46/16y _ , i/ A` e`i e Printed Name .1^ �e-P1') kl J_el, y Title Title 13.1 W„.2_ y4__ Date /S. Date C).e I 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. Pperty Owner Signature d ' %%,am -Signature Property Owner JiO Printed Name 61//e0r/V»%/%PrintedName �j ' S�IV!Ca' D n`1 YJYJ��e Wl lC Title lid ` f?ej0 Title P�►2-Ilc) 'h Date � -�] e-e- Date 9 - g. o --lb I hereby certify that I am the 1 ee 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.