2018-SINGLE FAMILY CONFIRMATION Return form to:
CITY OF FRIDLEY
� PLANNING DIVISION, ATTN: ZONING
Fr��i���� Community Development Department
6431 University Avenue, N.E. Fridley, MN 55432
Office (763) 572-3599 Fax (763) 502-4982
3s� •
My single-family home located at � / i� �/U�-+'l�,c",� �� ��� is not being used as a two
family dwelling based on the following reason(s):
(Please initial and date each that apply)
[_� � r ' ,
_�f�l�There is not a lockable door separating living spaces in the home.
�� �+JIy 1�The tenants have moved out or ara movir��g oui on 'r'�,��sQ� �z=��
The home is "Family Occupied"; I do not live in the home but other
family members occupy the property (son, daughter, parent).
(Family member/relationship : )
The boarder(s) living in the home with me are not family members
but share the common living areas of the home with me.
Other, please explain:
THIS INFORM TION IS CORRECT AND TRUE AS OF THE DATE SIGNED
L. n� �e-��./�
►'1 �wner 1 •wner 2
Print N me Print Name
Owner 1 Owner 2
Signature Signature
STATE OF MINNESOTA )
) ss.
COUNTY OF wt� L�' )
On this 3(� day of �.(���VL , 20 1`a , before me a Notary Public within
and for said County, personally appeared �'ivu�Lc� P1bY1��to me, who being by me duly sworn and
acknowledged said instrument to be the free act and deed of tfie entity.
��''<<�;�T4 �
���-������, AMBER LYNN SISOMBATH
"��.��r`:�;
a�: � ;�.: � NOTARYPUBLIC-MINNESOTA Notary Public
'��.�g���MY COMMISSION EXPIRES OV3112021
'�s�;�:�.