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Dane County Rezone & Application Date Petition Number <br /> 08/10/2016 DCPREZ-2016-11044 <br /> Conditional Use Permit Public Hearing Date C.U.P.Number <br /> 10/25/2016 _ <br /> OWNER INFORMATION AGENT INFORMATION <br /> OWNER NAME PHONE(with Area AGENT NAME PHONE(with Area <br /> HMG LIVING TR Code) BRENT JOLMA Code) <br /> (608) 576-0812 (608)228-6542 <br /> BILLING ADDRESS(Number&Street) ADDRESS(Number&Street) <br /> 1640 US HIGHWAY 12 & 18 1331 OKEEFFE AVE#107 <br /> (City,State,Zip) (City,State,Zip) <br /> DEERFIELD, WI 53531 SUN PRAIRIE, WI 53590 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JAHAAG5 @GMAIL.COM BPJOLMA @GMAIL.COM <br /> ADDRESS/LOCATION 1 ADDRESS/LOCATION 2 ADDRESS/LOCATION 3 <br /> ADDRESS OR LOCATION OF REZONE/CUP ADDRESS OR LOCATION OF REZONE/CUP ADDRESS OR LOCATION OF REZONE/CUP <br /> 1640 US HIGHWAY 12 & 18 1640 US HIGHWAY 12 & 18 <br /> TOWNSHIP TOWNSHIP SECTION TOWNSHIP SECTION <br /> COTTAGE GROVE 'SECTION <br /> 36 COTTAGE GROVE 36 <br /> PARCEL NUMBERS INVOLVED PARCEL NUMBERS INVOLVED =PARCEL NUMBERS INVOLVED <br /> 0711-361-8001-0 0711-361-8500-6 <br /> REASON FOR REZONE CUP DESCRIPTION <br /> SEPARATING EXISTING RESIDENCE FROM <br /> FARMLAND <br /> FROM DISTRICT: TO DISTRICT: ACRES DANE COUNTY,CODE OF.ORDINANCE SECTION I ACRES <br /> A-2 Agriculture District A-2 (4)Agriculture 6 <br /> District <br /> C.S.M REQUIRED? PLAT REQUIRED? DEED RESTRICTION INSPECTOR'S INITIALS SIGNATURE:(Owner or Agent) <br /> REQUIRED? <br /> ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No A /r, <br /> HJH3 ak <br /> Applicant Ini ia14 Applicant Initi sjg <br /> 7 <br /> Applicant In iti Is 411 PRINT NAME: <br /> FrPn`� R 7;7,114- <br /> DATE: <br /> -.- > -/10/i 6 <br /> Form Version 03.00.03 <br /> CSM/DOC: 1 1-1141 /5.2gRo ( I <br /> DEED RESTRICTION: <br /> DEED NOTICE: <br /> OTHER: <br />