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��'O>F MAd <br /> Town of Madison Application for Building Permit �o '�':4$ `p <br /> 2120 Fish Hatchery Road, Madison,Wisconsin 53713 ' I .g M $ <br /> For Inspection Call 608-210-7217 <br /> ❑Construction ❑ Erosion c—(61(1 CC 1i- -iarlat 4S'TAB 103 illitr- <br /> Owner's Name MGtTLI N g S Ff TUAirti <br /> Address �( W. W1/1141& 1!1W • MADISON, W( <br /> Phone Number <br /> Contractor's Name <br /> Ki AN STNS, 11■16• <br /> Address o 01 Pi(Al2Vi 111266T MADISON, W 1 '53113 . <br /> Phone Number <br /> (cam. tilt•1Pill <br /> Building Address Parcel Number__ <br /> famw <br /> Project [ New ❑Alteration ❑Addition ❑ Repair 1 Raze ❑ Move ❑ Other <br /> Occupancy - ❑ Single Family ❑Two Family ❑ Multi-Family- 0-Garage ❑Commercial <br /> Description <br /> Estimated Building Cost$ I(,0190 . 00 <br /> The applicant agrees to comply with all applicable codes, statutes and ordinances and with the conditions of this permit; <br /> understands that the issu. ce of the Rerm' crest-: o le I liability,express or implied, on the Department or municipality; <br /> and certifies that all t - a l�a informatio ,E' • rate <br /> Applicant's Signature <br /> de 4 Date Signed ` ' II,' (5'. <br /> Approval Conditions <br /> FEES: PERMIT-ISSUED B : <br /> I <br /> / <br /> Plan Review $ <br /> Inspection kl 5,5 to $ Q I ( 1 5---0 Name '` 2 <br /> HVAC4` $ <br /> Date 01 1 121 to 15 <br /> Erosion $ _ <br /> Penalty $ Cert. No. q S 3-71 <br /> Total r $ g t • s-O <br /> . 10 <br /> TR# i , Date I I 415 Amount Paid g i • CO--- GFS# <br /> IL <br />