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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
17922
TYPE: BLDG D HTG D ELEC $( PLBG D SIGN D ZONING FLOOD PLAIN HEIGHT
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OWNER
DESIGNER
USE/NATURE OF WORK
r~~/ ~~ r
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATINy CONTRACTOR
Heat D NC D Vent D Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR
/
Electric Servo New D Change D Temp D ype _ 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
6'
FEES: Valuation $ ~d~ermit Fee Paid $
ISSUED BY~~ . Date
I
~
/.5 ...-
AT-//-;?ZJ
Park Dedication $
Final/O.P. S? - (." -10
SIGNATURE
erform all work pursuant to rules governing the described construction.
ADDRESS
~~'"
1/ I'M
DATE
d$S-=-#7i
TELEPHONE #
PERMIT NO.
y - ( r -- ?c:::r
,
ELEC. CONTR.
OWttER
ADDRESS
NATURE OF WORK
ELEC. SERV. NEW
DESC. T~
FIX 'S........ SW I S
APPLIANCES .
b<
CHANGE
VOLTS
RECEPT'S
/:Y
TEMP.
AMPS
eIRC'S
S I"GNS
INSP. ROUGHIN fJ!.< 1/ !J?J;Jj -q6 SERVICE
EST. COST ;;Z t' (> ~ PERMIT FEE t 5"~
REMARKS
FINAL~.C-9t'
DATE PD.Y-/f-'!tJ
AFFIDAVIT RELATING TO SECTION 1:3.12 (c)OP A GENERAL ORDINANCE
OF THE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
} SS
WINNEBAGO COUNTY }
~~
~Au \D~~
. (Name )
/10 S ~q-!'oR'(
(Address)
J
first being duly sworn on oath, deposes and says that he 1s not
a l1censed electrician in the C1ty of Oshkosh and that he has
app11ed tor an electr1cal pe.rm1t to do e+ectr1cal work 1n a
res1dence and/or aux1l1ary bu11dings (1ntended solely for pur-
poses assoc1ated w1th a res1dence) wh1ch is owned and occupied
by h1m, or 1s be1ng constructed in h1s name, as hls personal
home and that sald residence or auxiliary bu1ldings be1ng so
wired are not to be used or erected for rental purposes or for
resale to present or prospective purchasers.
Aff1ant understands that the electr~cal work authorized by
the perm1t applied tor 1n connect10n with this affidavit, must
be done only by this atflant and that he. cannot employ others to
ass1st with the electrical work but members of his immediate
family.
Dated th1s
H
day
, 19 (Q
Subscr1bed and sworn to before
/I.~
_ , 19~.
Wlnnebago County, Wisconsin
t'-1 Comm1ss1on Exp1res: ~ '1,./99J--
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