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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
25909
FLOOD PLAIN
HEIGHT
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TYPE: BLDG 0 HTG 0 ELEC ~LBG 0 SIGN 0 ZONING
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USE/NATURE OF WORK
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(ft!~~
PLAN NO.
ADDRESS
OWNER
DESIGNER
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATING CONTRACTOR
Heat 0 AlC 0 Vent 0 Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR -~
Electric serv)(New D Change D Temp D Type_ Volls_ Amps_
Fixtures "- Switches ~ Receptacles ~ Circuits ~
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I(/T'
PLUMBING CONTRACTOR
_BT _WH _Disp _ WSoft _ CBasin
_Lav _Sh _OW _OF _ San. Sewer
_WC _FOr _SP _Ur _ Storm Sewer
_Sink _LTub _ Eject _SS _ Water
Other
ISSUED BY
I
L-"C. . V'
Permit Fee Paid $ !J ~
Date 10 -::2.-1-7 /
,
Park Dedication $
Final/O.P.
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:'~:A:~:~m~~ ~'~ag~ ~ pumuam to ,ules go~ming the described ronm::
G fOWNER
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DATE
ADDRESS
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TELEPHONE #
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AFFIDAVIT RELATING TO SECTION 13.12 (c) OP A GENERAL ORDINANCE
OF TEE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY )
{V'V<ti(
f iJRrHv
( Name )
,
>~ (') f+<'OSd'v
Address
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f1rst be1ng duly sworn on oath, deposes and says that he 1s not
a 1.1censed electr1c1an 1n the City of Oshkosh and that he has
appJ.-1ed for anelectr1cal perm1t to do e1ectr1cal" work 1n a
res1dence and/or aux1l1ary bu1ld1ngs (1ntended solely for pur-
poses assoc1ated w1th a residence) which is owned and occup1ed
by h1m, or 1s be1ng constructed 1n h1s name, as his personal
home and that sa1d res1dence or aux1liary buildings be1ng so
w1red are not to be used or erected for rental purposes or for
resale to present or prospect1ve purchasers. "
Aff1ant understands that the electrical work author1zed by
the perm1t applied for in connect1on w1th this aff1dav1t. must
be done only by th1s aff1ant and that he cannot employ others to
assist ~th the electr1cal work but members of h1s 1mmediate
fam1ly.
...
,,'.
Dated this 00 ';}of day
of , 1931.
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Subscr1bed and sworn to before
- .
this -~:!!- day of (Y~
~?f~
Nota;y ublic, W1nnebago
M1 Comm1ss10n Exp1res:
, 195./...
\v1scons1n
~
ELEC. CONTR.
DATE
t::J~;L(--7
PERMIT" NO. :?- 5 f t?
/'
OWNER
ADDRESS
NATURE OF WORK
JJCJ.-II-~
~ '--'
. . ~----
ELEC. SERVo NEW
DESC. TYPE
FIX I S c:><--. SW I S
APPLIANCES
CHANGE
VOLTS
P"- RECEPT' S
TEMP .
AMPS
t:X- CIRC I S ~
F-~
SrGNS .
INSP. ROUGHIN It'-I)"~ fl' elf SERVICE FINAL
EST. COST CJO.c.:..--' PERMIT FEE /rC?:::--- DATE PD/t1-;)-f-r,
REMARKS I
. I.