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AFFIDAVIT RELATING TO SECTIO~,IJ.12 (c) OPA.g~N;ggM9RpINANCE
OF THECITY():Ef"OSBKO~H""fiEtA?f!IfGTOT'HE:'Ll'C~NSIRG OF' ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WIsCoNsIN')
) 58
WINNEBAGO COUNTY )
,.
Kb~V~ 1\'\. ^\iwdod,.. , gt!:>DJ-/~Yrrlhl1rnrn f/<lL~
j Na~ : A dress
first being ~uly swo'rn on o~th, deposes and says that ,he i$ not
a lioensed electrician in tqe City of Oshkosh and that he has
applied for an electrical permit to do electrical work ,in a
residenoe and/orauxlliary buildlngS(intended solely for pur-
poses associated with a residence) which is owned and occupied
by him, or is being constructed in nis naII)e, as his personal
home and that said residence or auxiliarybulldings being so
wired are not to be used or erected for rental purpose's or for
resale to present or prospective purchaser:s.
Affiant understands that the electric,al 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
7
day Of~,
, 19U.
,)
Sub~erlb~d and sworn
,-~ ' >.1 J.
th1s ~y of .
~.~.~
to before
.'
~
Notary
My Commission Expires:
, 19~
County, Wisconsin
'-:J ',[;;0f~lMISSION EXPIR~
JULW 2Y, 198:1,
ELEC.
OWNER
ADDRESS
ATURE OF
CHANGE
VOLTS
RECEPT'S,Z:;--
TEMP.
AMPS
eIRC'S
!'"
ELEC. SERVo NEW
DESC. TYPE
FIX ' S ,/ SW' S /
APPLI~NCES (
!t
SIGNS
INSP. ROUG
EST. COS
REMARKS
SERVICE
PERMIT FEE '
, ,
~ ........-.-,.