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CITY OF OSHKOSH N~ 45561
PERMIT - APPLICATION AND RECORD
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ADDRESS if -¿ -z..-. ßttÁd ~
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PLAN NO.
OWNER
DESIGNER
USE/NATURE OF WORK ~Æ."-,,-. .&AAj/
BUILDING CONTRACTOR
Size
Foundation
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Class of Const.
HEATING CONTRACTOR
Heat 0 NC 0 Vent 0 Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR & áh-t./¿f
Electric Servo New 0 Change 0 Temp 0 Type - Volts - Amps-
Fixtures:3 Switches 2-- RecePtacies-'~ ~ Circuits I
PLUMBING CONTRACTOR
_BT _WH _Disp _WSoft - CBasin
_Lav _Sh _DW _DF - San. Sewer
_WC _FDr -SP _Ur - Storm Sewer
_Sink _LTub - Eject _SS _Water
Other
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FEES: Valuation $ J 00 . D D Permit Fee Paid $ 10 . 0" ./
ISSUED BY ~(./~~ Date ~/2.¿¡/ç r
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Park Dedication $
FinaVO.P.
~NATUR
.r4DDRESS
agree to perform all work ~ursuant to rules governing the described construction.
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TELEPHONE.
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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)
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WINNEBAGO COUNTY)
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(Name)
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(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 purposes 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 affiant and that he cannot employ others
to assist with the electrical work but members of his immediate family.
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Dated this 7.-0 day of
Subscribed and sworn to before
this - day of
.19_.
Notary Public, Winnebago County, Wisconsin
My Commission Expires: