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ERMUSR INFORMATION 1 11-15-2011 PETITION, WAIVER AND AGREEMENT FOR PAYMENT OF THE COST OF REPAIRS TO PRIVATE UTILITY LINES AND ASSESSMENT OF AMOUNTS PAID AS A SPECIAL CHARGE UNDER MINNESOTA STATUTES, SECTION 429.101 TO: City Council of the City of Elk River located at (the Owners), owners of the property Exhibit A attached hereto (the Property), and legally described on Petition the City of Elk River (the City) to pay the costs of certain repairs (the Repairs) to private utility lines located on the Property, including: Private water service lines Private sanitary sewer service lines In an amount not to exceed that set forth on Exhibit B attached hereto (the Cost of Repairs), And to levy a special assessment against the Property in the amount of the Cost of Repairs as an unpaid special charge pursuant to Minnesota Statutes, Section 429.101. Owners acknowledge and agree: 1) that there has been a failure of the utility lines on the Property; 2) that the failure of the utility lines has created a public health and safety hazard on the Property; 3) that the Repairs identified on Exhibit B are reasonable and necessary repairs to eliminate the public health and safety hazard on the Property; 4) that the Cost of Repairs identified on Exhibit B are reasonable and necessary to affect the Repairs and are the responsibility of Owners; and 5) that Owners have been provided the opportunity to pay the Cost of Repairs without the City's involvement and have elected, instead, to petition the City to pay the Cost of Repairs and to assess the full amount of the Cost of Repairs to the Property. Owners agree: 1) to have the Repairs identified on Exhibit B completed as required by the policies and ordinances of the City; 2) to submit evidence to the City that the Repairs have been inspected and accepted by the City Building Official; 3) that, upon completion and acceptance of the Repairs, City shall make payment to the Owner's contractor or other parties who performed the Repairs in an amount not to exceed the Cost of Repairs identified on Exhibit B; 4) that payment by the City of the Cost of Repairs shall create an unpaid special charge against the Property; 5) that this unpaid special charge shall be specially assessed against the Property by the City pursuant to Minnesota Statutes, Section 429.101; and 6) that the special assessment shall be payable in equal annual installments with interest accruing on unpaid installments at the rate of %. Owners represent and warrant that they are the sole fee Owners of the Property and agree to make payment of all assessments levied pursuant to this Petition, Waiver and Agreement for Payment of the Cost of Repairs. Owners expressly waive objection to any irregularity with regard to the assessment of the Property for the Cost of Repairs, expressly agree that the amount assessed is reasonable, expressly waive any claim that the amount assessed is excessive, expressly waive all rights of appeal, including any rights under Chapter 429, Minnesota Statutes, from the assessment by the City of the Cost of Repairs, and expressly agree to pay when due all assessments levied for the Cost of Repairs. Dated this day of , 20 OWNER By: Its: EXHIBIT A Legal Description EXHIBIT B Repairs: Cost of Repairs: GP:3070946 v I