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Dane County Rezone & Application Date Petition Number <br /> 08/17/2016 DCPREZ-2016-11049 <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 /> RENELLE CHAMPAGNE Code) PAUL HYNEK Code) <br /> BILLING ADDRESS(Number&Street) ADDRESS(Number&Street) <br /> 2822 N HILL ST W9501 BRITZKE ROAD <br /> (City,State,Zip) (City,State,Zip) <br /> COTTAGE GROVE, WI 53527 Cambridge, WI 53523 <br /> E-MAIL ADDRESS E-MAI •DDRESS <br /> Nit NS-V.123`A Grimm t...•corn <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 /> 2822 N Hill Road <br /> TOWNSHIP SECTION TOWNSHIP SECTION TOWNSHIP SECTION <br /> PLEASANT SPRINGS j 10 <br /> f :*11 00110 PARCILNUM$ RCIlAtainQ MIMI&NUM1**M VIpD <br /> 0611-102-9000-4 <br /> REASON FOR REZONE CUP DESCRIPTION <br /> SEPARATING EXISTING RESIDENCE FROM <br /> FARMLAND <br /> FROMDI ► TOO 141.4n -ACllt18 MAN CiOWnY:400t0t,010100161amanott. .. I <br /> A-1 Ex Exclusive Ag A-2 (4)Agriculture 5.7 <br /> District 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 /t,2 RWL1 <br /> Applicant Initials Applicant Initials Applicant Initials PRINT NAME: <br /> /K <br /> DATE: <br /> 7- // <br /> CSM/DOC. 11-t3V5 305G,5 Form Version 03.00.03 <br /> DEED RESTRICTIOl\ 305()55 <br /> DEED NOTICE: <br /> OTHER: <br />