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N2 35782
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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
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ADDRESS (2- 1.- 9 P ~M t/- . . PLAN NO.
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OWNER
DESIGNER
USE/NATURE OF WORK
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I
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATING CONTRACTOR
Heat D AlC D Vent D Fuel/System
Heat Loss
BTU'S
'"'
-"
ELECTRIC CONTRACTOR c'&"IYt/~ tfthA-R)f -e.-fA) ~ ~
Electric Servo New D Change D Te~ D Type _ Volts_
Fixtures ~ Switches / Receptacles----- Circuits
Amps_
....-
PLUMBING CONTRACTOR
_BT _WH _Disp _ WSoft _ CBasin
_Lav _Sh _OW _DF _ San. Sewer
_WC _FDr _SP _Ur _ Storm Sewer
_Sink _LTub _ Eject _SS _ Water
Other
FEES: VaIUatiO~ 0 ~ <::1 , P",mil Fee Paid $
ISSUED BY J.{ ~~ Date
(
I), <> 0 j
7h./9J
Park Dedication $
Final/O.P. I J r..J /1 ~
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In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE ~g
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AGENT/OWNER
6 ,.
. / ~a/f./k
/<-2-95
DATE
ADDRESS I ~ a 7
a~.3'- 723~
TELEPHONE #
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AFFIDAVIT RELATING TO SECTION lJ.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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(Nam
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/d~i ~tUCR
(Address)
first being ~u11 sworn on oath, deposes and says that he is not
a licensed e1ectric1an 1n the City of Oshkosh and that he has
app11ed for an electrical permit to do electrical work 1n a
residence and/or aux111ary bu1ld1ngs (intended solely for pur-
poses associated with a residence) wh1ch is owned and occup1ed
by him,. or is being constructed in his name, as his personal
home and that sald residence or auxiliary buildings being so
wired are not tabe used or erected for rental purposes or for
resale to present or prospective purchasers.
Arflant understands that the electrical work authorized by
the permit applied for 1n connection w1th this affidav1t, must
be done only by this affiant and that he cannot employ others to
assist w1th the electrical work but members of his immed1ate
family. >
Dated this Z day of ,dpf~ ' 1953
>Q~r~~~-
Subscribed and sworn to before
thi s .2AJ. day of "'J-i.at~ , 19lL.
/11L l~
Notary Public, Wlnnebago County, Wisconsin
My Commission Expires: ~..11 )9'1t.