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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
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Ng 46470
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ADDRESS . 902- .5 ~A~4 PLAN NO.
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OWNER
DESIGNER
USE/NATURE OF WORK
BUILDING CONTRACTOR
Size
Foundation
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Class of Const,_
HEATING CONTRACTOR
Heat 0 AlC D Vent D Fuel/System
Heat Loss
BTU'S
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.c r'=LECTRIC CONTRACTOR
Electric Servo New D Change D Temp D
Type
Volts
Amps_
Fixtures
Switches
Receptacles
Circuits
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PLUMBING CONTRACTOR
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_BT _WH
~Lav _Sh
-Lwc _FDr
_Sink
Other
_ LTub
_Disp
_DW
_SP
_ Eject
_ WSoft
_DF
_ CBasin
L-
_ San. Sewer
_Ur
_ Storm Sewer
_ Water
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FEES: Valuation $ 0 ... Permit Fee Paid $ ~ . Park Dedication $
ISSUED BY ~ ~ ------- Date 0/ ~.7' ,~- Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE ti/l//j;k,d 1/J (U~
, CI' AGE~T/OWNER
ADDRESS qJ '3 () r471t&LL~'
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TE PHONE #
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STATE OF WISCONSm )
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wnmEBAGO COUNTY )
/)/1;&6> j)!4/JUI-If
b (Name ).
Q)'"3 I3r S~Il/C~;rf 11- uE
(Address
being first duly sworn on oath deposes and says that he is not
a licensed plumber, and that he has applied for a plumbing
permit to the Plumbing Inspector of the City of Oshkosh, to do
plumbing work in a home owned and occupied by him, or a home
that is being constructed that is owned by him, and which will
be occupied by him as his home when completed. That he is not
building said home. for the purpose of sale.
This affidavit is made for the purpose of complying with
the provisions of the plumbing code of the City of Oshkosh and
the State of Wisconsin, which provides that all plumbing work
must be done by a licensed plumber except that the plumbing work
may be done by one who owns and occupies his own home providing
the installai:ion complies with the plumbing code of the City of
Oshkosh and the State of Wisconsin.
This affiant understands ,that '. the PlHmbing work authorized
by the permit applied for, must be done only by this affiant and
that he cannot employ others who are not licensed plumbers to
assist with the work.
Dated this
07.
day of
Oy. . .191t?
{!/~d~#
before me . .lI '
i' ,
Subscribed and sworn to
this
day of
, 19
.
I
Notary Public, Winnebago County, Wisconsin
My Commission Expires: