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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
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N! 46633
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~DDRESS 92."3 4~tLA-,(~ a~ PLAN NO.
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OWNER
6.
.,.
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 t/t'ffUq (iLiA' ~ ~J-~
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
o
Permit Fee Paid $
Date
I
/0..001
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,
Park Dedication $
Final/O.P.
ISSUED BY
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURK
ClcfAfi<7 I ~
7GEN'fIOWNER
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 PENAL TIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY)
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(Name)
elL-"3> f3/~ 0;..-<----
(Address)
first being duly sworn on oath, deposes and says that he is not a licensed electrician in the City of
Oshkosh and that he has applied for an electrical permit to do electrical work in a residence
and/or auxiliary buildings (intended solely for purposes associated with a residence) which is
owned and occupied by him, or is being constructed in his name, as his personal home and that
said residence or auxiliary buildings being so wired are not to be used or erected for rental
purposes or for resale to present or prospective purchasers.
Affiant understands that the electrical work authoriiedby the permit applied for in
connection with 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.
q~
.19&
Dated this
7
day of
4-
x: C1r.--< ~ / J)~
(7'
Subscribed and sworn to before
this
day of
,19_.
Notary Public, Winnebago County, Wisconsin
My Commission Expires: