HomeMy WebLinkAbout0012090-Electric (service change)
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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
12090
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USE/NATURE OF WORK
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PLAN NO.
ADDRESS
OWNER
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DESIGNER
:2 --l.o~)} '-).-OCJ
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATING CONTRACTOR
Heat 0 AlC 0 Vent o Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR _ #
Electric Servo New 0 ChangeA-..Temp 0 Type~ VOI~~tJ Amps2f) tJ
Fixtures X Switches rx:. Receptacles 16 Circuits t>S
qN,
PLUMBING CONTRACTOR
_BT _WH _Disp _ WSoft _ CBasin
_Lav _Sh _OW _OF _ San. Sewer
_WC _FOr _SP _Ur _ Storm Sewer
_Sink _ L Tub _ Eject _SS _ Water
Other
J ,-; 9-- 7"
--.----.. Permit Fee Paid $;2../J .
Date /-/tJ - '3'7
ISSUED BY
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 a~L ~J~/L--
AGENT/OWNER
330 ~
ADDRESS
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DATE
C-( 210 - J-l 7-7
TELEPHONE #
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AFFIDAVIT :aEI..ATIbiG ':rO SE9~J:Olllj .12 (c) OF A GENERAL ORDINANCE
OF THE CITY OF OSHKOSH IiSLATING TO THE UCENSING OF ELECTRICIANS
AND PROVIDING PENALTIES'
STATE OP WISCONSIN)
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W INNEBAGO COUNTY )
Z]v,'u ~"eeif
(Na
330
,
U~y,V\
(Address)
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t1rst be1ng duly sworn on oath, deposes and says that he 1s not
a 1.1censed electrlc1an 1n the, Clty ot Oshkosh and that. he has
appl:led for an electr1cal perm1t to do electrical work in a
resldence and/or aux1l1ary bUildings (lntended solely for pur-
poses associated with a resldence) wh1ch is owned and occup1ed
bY' him, or ls 'be1ng constructed 1n hlsnaate, as his personal
home and that sald resldence orau:c111ar'Y bulJ.dlngsbelng so
wired are not to be used or erected tor..re%1t2.l purposes or tor
resale to present or prospect1ve purchasers.'
Afflant understands that the e1ect1"1calworks'\lthorl;ed by
the permit applied for ln connect10n wlth thlsa.ft1davit, must
be done only by this aftiant and thai:p.e ~a%1::lotemp1oy others to
assist with the electrical work but members of his lmmediate
family. '
Dated this
to
day of ffM~
!;dd /f;.41l9~
. / ~,.
, 19 Z1..
Subscribed and sworn to betore
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Wlnnebago County, Wisconsin
My Comm1ssion Exp1res: 0-pV~ 7 /99;2.)
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OWNER &.,~. .
lIDDRESS _ ~ 1& ~~
NATURE OF WORK -
ELEC. SERVo
D_-,-C. TYPE
FIX'S IX
APPLIANCES'
TEMP.
AMPS CJ
CIRC'S<'
SIGNS
INSP. . ROUGHIN 1..S---
EST. COST .r oCJ
REMARKS
SERVICE . . e... . FINAL
PERMIT FEE ~L' Cl-- DATEPD./-lcJ-$7