Lino Lakes Community Development Fema - Elevation Certificate Application Form
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1Community Development
FEMA - Elevation Certificate Application Form
CHECK APPLICATION TYPE(S):
REQUIRED FEE:
ESCROW
DEPOSIT:
$200
$0
Elevation Certificate
With elevation information
$200
$1000
Elevation Certificate **
Requiring Elevation Survey by City
TOTAL AMOUNT DUE: ______________________________
ESCROW DEPOSIT
**In addition to the application fee, an
is required for review of this land use request in
the amounts established by the City of Lino Lakes Fee Schedule. The following amount is required at the time
of application submittal.
*
An escrow account shall be established to cover all expenses incurred by the City as part of the application review. The
applicant is responsible for all costs incurred by the City during plan review. If the escrow account drops below 10% of
the original deposit amount, the City will require the submittal of an additional escrow deposit sufficient to cover any
anticipated expenses. Upon the City’s determination that the project is complete or expired, the City will return any
remaining escrow to the applicant
Property Address: __________________________________________________________________________
PIN # _ _ - _ _ - _ _ - _ _ - _ _ _ _ Legal Description: Lot ___ Block ___ Subdivision____________________
Applicant:
Name:
Phone:
Address:
Cell:
City:
State:
Zip:
Fax:
E-mail:
Please note: In signing this application, I hereby acknowledge that I have read and fully understand the
applicable provisions of the City Ordinances and current administrative procedures. I further acknowledge the
fee explanation and hereby agree to pay all statements received pertaining to additional application expense and
city review.
Signature___________________________________________________Date___________________
Revised 11/21/2014
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