HomeMy WebLinkAboutElectric CITY OF OSHKOSH NOM 00201
PERMIT APPLICATION AND RECORD
TYPE: BLDG HTG ❑ ELEC PLBG [] SIGN D ZONING FLOOD PLAIN— HEIGHT--
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ADDRESS—-,-, "C27N.— PLAN NO.
OWNER--—
DESIGNER--....--, .—.
USE/NATURE OF WORK....._ ......
BUILDING CONTRACTOR—
Size Sq. Ft, ...—,-. # Rooms # Stories Height
Foundation Class of Const.,--- Occupancy Permit
HEATING CONTRACTOR_
Heat F-1 A/C [-] Vent 0 Fuel/Systern Heat Loss
ELECTRIC CONTRACTOR—... .-
Electric Serv, New [-] Change Temp Type --- Volts Amps
Fixtures1->�.— Switches Receptacles Circuits
PLUMBING CONTRACTOR
BT —WH Disp wsoft ClBasin
Lav —Sh DW —DF San. Sewer
WC —FDr SP —Ur Storm Sewer
Sink LTub Eject —SS Water __
Other
FEES: Valuation t Permit Fee Paid $ Park Dedication $
ISSUED BY —7
Date Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE—,
-
AGENT/OWNER DATE
ADDRESS
TELEPHONE
AFFIDAVIT RELATING TO SECTION 13-12 (c ) OF A GENERAL ORDINANCE
OF THE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY
4A V I,
(Name ) (Address)
first being duly sworn on oath, deposes and says that he Is not
a licensed electrician in the City of Oshkosh and that he has
applied for an electrical permit to do electrical work In a
residence and/or auxiliary buildings (intended solely for pur-
poses associated with a residence) which Is owned and occupied
by him, or Is being constructed in his name , as his personal
home and that said residence or auxiliary buildings being so
wired are not to be used or erected for rental purposes or for
resale to present or prospective purchasers.
Affiant understands that the electrical work authorized by
the permit applied for in connection with this affidavit , must
be done only by this afflant and that he cannot employ others to
assist with the electrical work but members of his immediate
family.
jf
Dated this j day of
iF
iF
I'Subscribed and sworn to before '
this 19
day of
Notary Public, Winnebago County, Wisconsin
MY Commission Exp ires: