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• <br /> • <br /> � I <br /> TOWN OF BLACK EARTH <br /> NOTICE OF INTENT TO REQUEST A ZONING CHANGE <br /> NAME: <br /> t v( i <br /> ADDRESS: a3-) �,��LIY ll � ea <br /> OA&k ,(XX c3\ 531 N . <br />{ PHONE: ),(A)„,-C'r <br /> 1.PURPOSE: 150 ( )(\) f\Q('.c o V\ 00(2 <br /> j I <br /> 2.LEGAL DESCRIPTION OF PARCEL IN REVIEW: <br /> > ■oQ cA- , Y <br /> Sec. <br /> 3.ATTACH A SKETCH OF PARCEL SHOWING: <br /> A. ROAD LAYOUT <br /> B. DIMENSIONS OF LAND (INCLUDE PROPOSED DIVISION IF APPLICABLE) <br /> C. LOCATION OF DWELLING, OUT BUILDINGS OR ADDITIONS <br /> 4.MISCELLANEOUS INFORMATION: <br /> I (we) agree to proceed in accordance with the town's ordinances and <br /> plans. <br /> •DATE: 4, ,fq2) SIGNED: A\At,y\ajcL T-Clubd-2) <br /> DATE FILED: - `/ - 72, TOWN CLERK: tlf,r( <br /> PLANNING COMMITTEE ACTION: DATE: <br /> BOARD ACTION: DATE: <br /> APPLICATION FEES RECEIVED: CULVERT/ REZONING/ <br /> ROAD CONDITIONAL <br /> ACCESS USE <br /> 5PG-BE92. 01 (3/92) <br />