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,____,...„,, <br /> 4.4-,„. ....,.,„ <br /> ,� ;� ,��� Dane County Planning & Development <br /> ;; aco . Zoning Division <br /> Building Numbering System <br /> Address Supplies Order Form <br /> Name: Gt. U c . . iv i4--(.,- <br /> Mailing Address: <br /> Post Office and Zip Code: <br /> Telephone Number: <br /> /7r v <br /> Property address number and road name forreplacement placard: <br /> - 5-170 3 0 0 r-e-r g--C1 <br /> Pl ease Deliver to: (check one) Mailing Address Property Address <br /> Other, please describe ( ) <br /> (Address supplies cannot be delivered outside of Dane County,if you would like to have your supplies shipped please contact us directly) <br /> ADDRESSING SUPPLIES Quantity COST Total <br /> Placard, Numbers, Hardware @ $15.00 each <br /> Post / @ $10.00 each <br /> Address Assignment @ $15.00 each <br /> Replacement Number(s) (indicate number(s)below) 65 @ $1.00 each <br /> Checks Payable to:Dane County Zoning Total $ --------- <br /> Additional Instructions: <br /> 210 Martin Luther King Jr.Blvd.❖City-County Bldg,Room 116❖Madison,WI 53703-3342❖Phone:608.266.4266• Fax:608.267.1540 <br /> H:\Zoning\RURAL ADDRESSING\_Documentation\address_supply_order_form_090915.docx <br />