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2009 band Use Application Form Page 2 2/20/2009 Last ModiSed Ap~licanjt Inf~ormation /,~ Name: ~ /'~ t\ i 11 t V ~+~ h ~ ~ ~~ E-mail address`s _ ~ (,C~ CX ~ ~'(/..5~ ~ ~r'! ~Cd ~~~ Address; a~~~ ~ ~I.~ \~ I ~0 ~(1~~fiL~ ~ ~ ~ f` ! U •t ~ /i ,~ ,.~ ~ .~.~ Street -~ Ciry State Zip Code Phone (w): Fax; Phone (I-I)• I prefer that my copy ofstaffreports be sent by.• 1B~ Class Mail ~ Fax ~ E-mail ~ (Check one) Sigtiat<irei Print Name; Date: Property Owner Information Same asAppllcanr ~ Different, asbelow ~ (Check one) Name: E-mail address: Address: Street City State Zip Code Phone (w): Fax: Phone (I~• I prefer thatmy copy ofstaffreports be sent by.• 13~ Class Mail ~ Fax ~ E mail ~ (Check one) Signature: Print Name: Date: Billing Information Same asApplicant ~ Same as propettyOwner ~ Different, as below ~ (Check one) Name: E-mail address: Address, Street City State Zip Code Phone (w): Fax: Phone (FI): Signature: Print Name: Agreement to Pay Costs of Review: Date: It is the policy of the City of Elk River to require applicants for land use approvals and licenses to reimburse the Ciry for costs incurred by the City in reviewing and acting upon applications, so that these costs are not borne by the taxpayers of the Ciry. These costs include all of the Ciry's out-of-pocket costs for expenses, including the City's costs for review of the application by the City's environmental Consultant, City Engineer, City Attorney, or other consultants, recording fees, necessary publication costs excluding public hearing notices, and may also include a charge fox extra staff time to process particularly complex applications. The City will invoice the applicant for these costs as they are incurred, and payment will be due within thirty (30) da}=s. If payment is not received as required by this agreement, the City= will suspend the application re~riew process and may deny the application for failure to comply with the requirements for processing the application, Payment for costs will be required whether the application is granted ox denied. The undersigned has received the Ciry's policy regarding the payment of costs of review, understands that reimbursement to the Ciry of costs incurred in reviewing the application will be required as set forth in the policy, agrees to reimburse the City as required in the policy and make payment when billed by the City, and agrees that the application may be denied for failure to reimburse the City for costs as provided in the policy. 5ignat[~g~ J! ,EP~ ~~. ~./`•iC/~=-~(_.(i~/i•- Date: -~~~0/d Print Name: ~ t" ~ W Q ~~'i° ~ J S:\PLANNING MAIN\Adnun\Application Forms\Land Use Application Form 2009.doc