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TOWN OF COTTAGE GROVE <br /> Notice of Intent for Change of Land Use <br /> 1. APPLICANT 2 . OWNER (if diff. the Applicant) <br /> Name OU 6 2 HA ,s-TCH Name e iZIAN DON n. 1- r2_ <br /> Addr. ( STAGY LANE Addr. 1779 5, 5Ak&o R0 <br /> MAO I So N (-v = itO C k <br /> ZIPS371(P Phone Goe-,221- 9743 ZIP r31 Phone 761-4 -56)03 <br /> 3 . DESCRIPTION AND LOCATION OF LAND <br /> Parcel No. 0 7 1 1 - 9 1 - 1(0 9 0 - Parcel Size r7, 2, A.CAts- <br /> Parcel Addr. I CQoo (--s- ",EM H(#) N 0 120A11 <br /> Description L q ; 1 N6 /'i " Xi- 7- 1 1 <br /> 4 . ACTION REQUESTED (Circle requested change and complete line. ) <br /> (: Zone Change from A y- to A -6Z for 1 Cr, acres. <br /> (c, rr ''3 A-cads, <br /> b. Conditional Use Permit for acres. <br /> c. Variance to Town Ordinance # <br /> AUA tTIoN AL. <br /> d. Other (desc. ) f'l�f(o 130�t�kL -AHo�Nr$s <br /> /OP�PIQ is#r �4Tf^cN' <br /> 5. ADDRESSES OF NEIGHBORING LANDOWNERS <br /> Name Ku r -+ C2L.og►/V K U.S_5o -) Name QAOL MA f0tn) LOrf <br /> Addr. 1 C S l NortT?t 1-AR .a PO Addr. 38Coo Qf02 FIELD AD , <br /> 0 <br /> 60'4 1=�p - 53531 i-ER 16_D wz 535-31 <br /> Name 0JC14AkV1 •1- (3RtNvA KAPRAL, Name eiz.1C4 ONST <br /> Addr. I (Q 2c1 toRTk '-s 4R1,c 12.n Addr. O1'Z F/lll) l <br /> o662cl Dt wz 3:531 1JL'1:RFI L� WI 53,5-3I <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 change will NOT be considered until this form <br /> is satisfactorily completed. <br /> 8. A fee of $20. 00 must accompany each application. <br /> Signed: I aa•�vi,� c1/1 (q91 ) Signed: <br /> pplicant De Town Clerk <br />