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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
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PLAN NO.
ADDRESS
OWNER
DESIGNER
USE/NATURE OF WORK
BUILDING CONTRACTOR
Size
Foundation
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Class of Const.
HEATING CONTRACTOR
Heat D AlC 0 Vent 0 Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR ()~
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Electric Servo New 0 Change 0 Temp 0 Type_ Volts_ Amps_
Fixtures ~ Switches ---- Receptacles .----- Circuits ,,---
PLUMBING CONTRACTOR
_BT _WH _Disp _ WSoft _ CBasin
_Lav _Sh _DW _DF _ San. Sewer
_WC _FDr _SP _Ur _ Storm Sewer
_Sink _ L Tub _ Eject _SS _ Water
Other
FEES: Valuation $ dOO, D D
ISSUED BY ~~(UA~
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Permit Fee Paid $
Date
I
1':[.oJ ,,/
f/t~h r
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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AGENT/OWNER
8 - (0 - 'iLl
DATE
ADDRESS
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)
} SS
WINNEBAGO COUNTY )
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(Address)
first be1ng duly sworn on oath, deposes and says that he is not
a lioensed electrio1an 1n the C1ty of Oshkosh and that he has
app~1ed for an electrical permit to do electrical work 1n a
residenoe and/or auxiliary bu11d1ngs (intended solely for pur-
poses assoc1ated w1th a res1dence) wh1ch 1s owned and occup1ed
by him, or 1s belng constructed 1n hls name, as h1s personal
home and that sald resldence or auxiliary bu11dings belng so
wlred are not to be used or erected for rental purposes or for
resale to present or prospectlve purchasers.
Affiant understands that the electrical work authorized by
the permlt applied for 1n connect1on w1th this aff1dav1t, must
be done only by this aff1ant and that he cannot employ others to
ass1st with the electrical work but members of h1s 1mmediate
family.
/ 0 day of c:[/^/___ , 191L..
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Subscribed and sworn to before
Dated this
th1s
day ot
, 19_-
Notary Public, W1nnebago County, W1scons1n
My Comm1ssion Exp1res:
"f'L
PERMIT NO. '1/00'5
ELEC. CONTR. c1~
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ADDRESS /b5~ Ii~~#~~..
NATURE OF WORK
. APPL. DATE
OWNER
ELEC. SERVo NEW
DESC. TYPE
FIX'S SW'S
APPLIANCES
CHANGE
VOLTS
RECEPT' S .
TEMP .
AMPS
CIRC'S
SIGNS ~
INSP. ROUGHIN 9; :7 If Y
EST. COST
REMARKS
SERVICE
PERMIT FEE
FINAL.3/wfq('
DATE PD.' "