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Address /Street Location of Property : Xerxes Ave. North and Cou R 10, Brooklyn Center, MN
Legal Description of Property "See Attached"
A preliminary meeting with the Planning Staff is required prior to the submission of a Planning
Commission application. No application will be accepted prior to such meeting.
Applicant Information: Owner Information:
Name Loren Van Der Slik Name Loren Van Der Slik
Address 101 South Main St., Dickson, TN Address 101 South Main St., Dickson, TN
Phone (615)446 7109 Fax (615)446 -7105 Phone (615)4.46- 7109 Fax (615)446 -7105
Email Email
Type of Request: F-1 Rezoning ($1050) Special Use Permit ($200)
0 Subdivision Approval ($300) o Site & Building Plan Approval ($750)
l_= Planned Unit Development ($1800) Appeal ($200)
o Variance ($200) FI Other:
Description of Request: Planned Unit Development, Submitting Preliminary Plat,
and Site and Building Plan Approval for the Shingle Creek Crossi
development. n
Application Fee $ , - Acct No. 10100 -4403 Receipt No. / p5 a
The applicant requests processing of this application and agrees to pay to the City of Brooklyn Center, within
fifteen (15) days after mailing or delivery of the billing statement, the actual costs incurred by the City for
Engineering, Planning and Legal expenses reasonably and necessarily required by the City for the processing of
the application. Such costs will be in addition to the application fee described herein. Withdrawal of the
application will not relieve the applicant of the obligation to pay costs incurred prior to withdrawal.
j � t
Loren Van Der Slick
Applicant (Please Print) r Applicant's Signature
Page 1
City of Brooklyn Center - Business and Development - 6301 Shingle Creek Pkwy - Brooklyn Center MN 55430 763. 569.3300
Planning Commission Application Form 10 »10
City U,re Only City Use Only City Use Only
Planning Commission Recommendation
Dates of PC Legal Notice Notices Mailed Action Taken Approved
Consideration Published Resolution No.
Approved 11 Denied this 2 day of
subject to the following conditions:
Chairman
City Council Action
Dates of Council Legal Notice Notices Mailed Action Taken Approved Performance
Consideration Published Resolution No. Bond
Received
Approved ❑ Denied this day of MA 20
with the following amendment:
C
Clerk/Planning Commission Aecretary
Page 2
City of Brooklyn Center - Business and Development- 6301 Shingle Creek Pkwy - Brooklyn Center MN 55430 763 - 569 -3300
Planning Commission Application Fonn 10.10