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TOWN OF BLOOMING GROVE <br /> Notice of Intent for Change of Land Use REL -I `..!_ <br /> 1. APPLICANT / )W(\-P( 2. OWNER (if different than Applicant) <br /> Name: 5'1--t' of S (4 I Yf Name: <br /> Pr. <br /> Addr: `3 3 3 f=,° m rite [/ r- Addr: <br /> mod ∎Sor1 1,,,t 6-37 /F <br /> Zip:93 717 Phone: 2 C 1- 8 5.. Da Phone: <br /> Zi p: <br /> 3. LOCATION & DESCRIPTION OF LAND (Use additional sheet if needed.) <br /> Tax Parcel No.: 0 - 7 2. 1 •, Parcel Size: 11 Q e�2.S <br /> Parcel Addr.:n�t 9 fa( e 1 � 0P 3 3 Fr rn r I ha' d r_ fr00'60 r‘ 1,41 '5 7-7,1 <br /> Legal Description: Se r- i3'H-CI C h y d S 1'i r-t f I <br /> Scale drawing that shows acreage/square footage: (Use additional sheet if needed.) <br /> s-C 61'1-G c 11*P c (- <br /> 4. ACTION REQUESTED (circle requested change & complete the information)D,eD. 14Therti,4 339 <br /> A. Zo,, 'ange from • for acres. 1' Q r2 f Pi C v f' 0 e r d <br /> B. Condition. - - •:sis't for acres. re S'l•r 1( i".10 )1 _44 2 ' - <br /> 0 cha' rlf-R Detd JeS\r) it -lorl <br /> . - .Hance to Town Ordinance Num.-r— • .Fk 1 -r R l 1 o 0 t 1.S),d P St,yr a yC, <br /> See /-A ( iie S/J�el j 3 <br /> 5. WRJI"IEN STATEMENT OF PROPOSED USE AND TIME SCHEDULE FOR — <br /> DEVELOPMENT(Use additional sheet if needed.) j L p r0 I.') d C <br /> 0,1,-c d ( s)--oloye F0:7r- rno-o{ v-rh ;(QIS - <br /> lvars� Cum/' lS _ <br /> Cvnsj` rucHon ete_tfitmrnf- ec - ,.., ih.- t-, ; n )--) -( 4-e ).- 2 yrs = <br /> 6. ADDRESSES OF NEIGHBORING LANDOWNERS (Use additional sheet if needed.) <br /> WITHIN 300 FE T OF ROPERTY. // / <br /> Name: I�rlGry4Y-' 1 S , .0 Name: � 4 0 /Y7ef-,.r S�`'�? <br /> j z <br /> Addr.: 3 3 17 F-'Yr, r I �`r D r- Addr.: / <br /> mOlA i50 WI . 3 7/7 <br /> Name: c oPi Fo 1 T Ia ri - rrr{r)-( 4 Name: Sa ,.-.-e C.----b.-0-)d(_ <br /> Addr.: L/6 to Ll n 1 vi rS 4 1 1 4 V r'n v r' Addr.: 3 , o P--„,12-c,t-C, _ <br /> rn G 0 .s • w y1(N4t,itc - 3-3 1 13 j <br /> I �"■ <br /> CiCa )•'&e-or-y- - Je e_ A--7 11 th 1) <br /> I hereby certify that the information provided on this notice is true and correct. I understand that failure to <br /> provide all required information shall be grounds for denial of my request. I also certify that no other change <br /> has been requested o this/these parcel(s) in the last twelve (12) months. <br /> Instructions for completion of this <br /> Applicant Date form are on the back of this form. <br />