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•► • TOWN OF COTTAGE GROVE •4 <br /> Notice of Intent for Change of Land Use <br /> 1. APPLICANT 2. OWNER (if diff. the Applicant) <br /> Name SIP/OK 4010E34' Name <br /> Addr. Addr. <br /> ,1400/-5.04 GUI <br /> ZIP VPhone 2. 2.7Wo ZIP Phone <br /> 3. DESCRIPTION AND LOCATION OF LAND <br /> Parcel No. og^o 7/106419 ceag Parcel Size <br /> Parcel Addr. <br /> Description <br /> 4 . ACTION REQUESTED (Circle requested change and complete line. ) <br /> a. Zone Change from'W- \ to $-1 for A a.* acres. <br /> b. Conditional Use Permit for acres. �N� e <br /> c. Variance to Town Ordinance # <br /> d. Other (desc. ) <br /> 5. ADDRESSES OF NEIGHBORING LANDOWNERS <br /> Name FIL4 Name <br /> Addr. Aeoli odza. a," 44.pstaa Addr. <br /> Name Name <br /> Addr. Addr. <br /> 6. Please attach a sketch or map of the parcel showing existing and <br /> proposed structures, existing and proposed roadbeds, tillable land, <br /> sewage disposal systems, and description of proposed land use. <br /> 7. The Town will notify surrounding landowners of the requested land use <br /> change. Your request for c. - • .e will NOT be considered until this form <br /> is satisfactorily comps= ed. <br /> 8. A fee of $20.00 m -t •cco�� - .ny each application. <br /> Signed: .1'q/ Signed: <br /> Appl ' ant Date Town Clerk <br />