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N2- - 47198
CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
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DESIGNER ~
USE/NATURE OF WORK R. ~~U ~7 :r d~~/~
ADDRESS
PLAN NO.
OWNER
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATING CONTRACTOR
Heat 0 NC 0 Vent 0 Fuel/System
Heat Loss
BTU'S
-è
ELECTRIC CONTRACTOR
Electric Servo
New 0 Change 0 Temp 0
Type - Volts - Amps-
~~
Fixtures
Switches
Receptacles
Circuits
PLUMBING CONTRACTOR
..l BT - WH
'LLav _Sh
-Lwc _FOr
(I)~
_Disp
_OW
_WSoft
_OF
- CBasin
- San. Sewer
c
-SP
_Ur
- Storm Sewer
_Sink
_LTub
- Eject
-SS
_Water
Other
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FEES:Valuation$ 1006>.00 Permit Fee Paid $ 1.-z.OV)
ISSUED BY ~~ Date 'J - /f?' ~ 5..s-
Park Dedication $
Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
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. AGENTfOWNER
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9://gN:;-
DATE
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TELEPHONE'
ADDRESS
STATE OF WISCONSIN
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WINNEBAGO COUNTY
¡"v\ I ('Ai ¡q~ / (1141 F.e~
Name.
(053 W fOù12jZJI4Vc
(Address )
being first duly sworn on oath deposes and says that he is not
a licensed plumber, and that he has applied for a plumbing
permit to the Plumbing Inspector of the City of Oshkosh, to do
plumbing work in a home owned and occupied by him, or a home
that is being constructed that is owned by him, and which will
be occupied by him as his home when completed. That he is not
building said home for the purpose of sale.
This affidavit is made for the purpose of complying with
the p~isions of the plumbing code of the City of Oshkosh and
the State of Wisconsin, which provides that all plumbing" work
must be done by a licensed plumber except that the plumbing work
may be done by one who owns and occupies his own home providing
the installat~on complies with the plumbing code of the City of
Oshkosh and the State of Wisconsin.
f"-
Th~s affiant understands that the Plumbing \>iOrk authorized
by the permit applied for, must be done only by this affiant and
that he cannot employ others who are not licensed plumbers to
assist with the work. . - .
Dated this --L&:.- day of s:.ß~ . 19 ý'g
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Subscribed and sworn to before me
this - day of
, 19_.
Notary Public, Winnebago County, Wisconsin
My Commission Expires: