4.b Hartley application to amend bakken dev agmtU
File Nox-2 I ] -U 3 Q
APPLICATION FOR PLANNING AND ZONING REQUEST
City of Scandia, Minnesota
14727 209th Street North, Scandia, MN 55073
Phone 651/433-2274 Fax 651/433-5112 Web http://www.ci.scandia.nui.us
Please read before completing: The City will not begin processing an application that is incomplete. Detailed submission
requirements may be found in the Scandia Development Code, available at the City office and website (wNvw.ci.scandia.mn.us) and in
the checklist forms for the particular type of application. Application fees are due at the time of application and are not refundable.
1. Property Location: (street address, Y'applicable)
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2. Washington County Parcel D:
as, & 3Q .12 00 QS
3. Complete Legal Description: (attach if necessary)
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4. Owner(s)
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Street Address: Go�rl 2 �$ � �1
City/ State: bV�,owx,t,,,�, , IM 4,
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5. Applicant/Contact Person:
Street Address (Mailing): c�� C`�a m T–r
City/ State: n+
6. Requested Action(s): (check all that apply) ~
Variance
Variance Extension
Conditional Use Permit (CUP)
CUP Extension
CUP/ Open Space Subdivision.
CUP/ Planned Unit Development
Interim Use Permit (iUP)
Annual Operators Permit
Administrative Permit
(hype)
Site Plan Review
(type)
XSite Plan Modification
Site Plan Extension
Sign (Permanent)
Phone:
(h) q 3 7 5-73 7 717
(b) ? 7 S- &-7
E -Mail: �rc�v�rJ �I wrrw,rt �f�ynar`�: �,I
Zip:5 5 6"f 2 -
Phone:
Phone: 6 j-3trfl a 7L
(h)
(b)
E -Mail:
Zip: s5d;�5
Amendment (Development Code)
Amendment (Comp. Plan)
Subdivision, Minor
Subdivision, Preliminary Plat/Major
Subdivision, Final Plat
Environmental Review
Wetland Review
7. Brief Description of Request: (attach separate sheet if necessary; include Variance Rationale if
necessary)
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8. Project Name:
I hereby apply for consideration of the above described request and declare that the information and materials
submitted with this application are complete and accurate. I understand that no application shall be considered
complete unless accompanied by fees as required by city ordinance. Applications for projects requiring more than one
type of review shall include the cumulative total of all application fees specified for each type of review. I understand
that applicants are required to reimburse the city for all out-of-pocket costs incurred for processing, reviewing and
hearing the application. These costs shall include, but are not limited to: parcel searches; publication and mailing of
notices; review by the city's engineering, planning and other consultants; legal costs, and recording fees. An escrow
deposit to cover these costs will be collected by the city at the time of application. The minimum escrow deposit shall
be cumulative total of all minimum escrow deposits for each type of review required for the project, unless reduced as
provided for by ordinance. The city may increase the amount of the required escrow deposit at any time if the city's
costs are reasonably expected to exceed the minimum amount. Any balance remaining after review is complete will
be refunded to the applicant. No interest is paid on escrow deposits.
PLEASE NOTE: If the fee owner is not the applicant, the applicant must provide written authorization by the fee
owner in order for this application to be considered complete.
Property Fee er Signature(s) Date:
pplicant Sign Date:
m
For City Use Only PAID
Application Fees:DT 2 9 2018
Escrow Deposit: o f f! 0d 0
r • CITY Of SCANDIA