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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
N2
08420
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ADDRESS
PLAN NO.
OWNER
DESIGNER
USE/NATURE OF WORK
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
ELECTRIC CONTRACTOR
Electric Serv. New 0 Change 0 Temp Type- Volts- Amps
Fixtures cI--- Switches ~RecePtacles ~ircuits ~- ~..--'
PLUMBING CONTRACTOR
_BT
_WH
_Sh
_Disp
_DW
_WSoft
_DF"
- CBasin
_Lav
- San. Sewer
_WC
_FDr
_LTub
-SP
_Ur
- Storm Sewer
_Sink
Other
_Eject
-SS
_Water
/
I"~V'
Permit Fee Paid $ L"r-
Date S- -:?-% - n
Park Dedication $
Final/O.P.
ISSUED B
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
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DATE
ADDRESS
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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 pur-
poses associated with a residence) which is owned and occupied
by him, or is being const:ructed. in his Mme, as his personal
home and that said residence or auXiliary buildings being so
wired. are not to be used or erected.fôr rental purposes or for
resale to present or prospective purchasers.
Affiant understands that the electrical work authorized by
the permit applied for in connection Wi th 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.
Dated this
-Z"S
day of
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Subscribed and sworn to before' \J
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Notary Public, Winnebago County, Wisconsin
My Commission Expires: xls-I¡qq()
, 19,M.
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PERMIT NO.
õ't/7-0
. DATE
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ELEC. CONTR.
OWNER
ADDRESS
NATURE OF WORK
ELEC. SERVo
DESC. TYPE
FIX'S tx
APPLIANCES
NEW
)fI-/(J,.
ANGE
VOLTS
RECEPT'S ~
TEMP.
AMPS
CIRC'S tš
SIGNS
INSP. ROUGHIN d(
EST. COST IFO~-
REMARKS
SERVICE FINAL
PERMIT FEE / ~ 0:::::--' DATE PD. ç--;2.5'-ø¥'
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