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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
17920
TYPE: BLDG 0 HTG 0 ELEC 0 PLBG~ SIGN 0 ZONING FLOOD PLAIN HEIGHT
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OWNER
190r :1',-, L7
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PLAN NO.
ADDRESS
DESIGNER
USE/NATURE OF WORK
A~4 ~~V
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BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Class of Con st..
Height
Occupancy Permit
Foundation
HEATING CONTRACTOR
Heat 0 AlC 0 Vent 0 Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR
Electric Servo
New 0 Change 0 Temp 0
Type_ Volts_ Amps_
Fixtures
Switches
Receptacles
Circuits
PLUMBING CONTRACTOR
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OC.{./"""1'"'l (?/\.
_BT
-I- Lav
_WC
_WH
_Sh
_Disp
_ WSott
_DF
_ CBasin
_Sink
_FDr
_ L Tub
_DW
_SP
_ San. Sewer
_Ur
_ Storm Sewer
_ Eject
_SS
_ Water
Other
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,v V
Permit Fee Paid $ (n
Date 4-II~rlJ
Park Dedication $
Final/O.P.
In the performanc
ork pursuant to rules governing the described construction.
SIGNATURE .J-
DATE
ADDRESS
TELEPHONE #
if
STATE OF WISCONSIN )
) SS
WINNEBAGO COUNTY )
- ~"\3)~~ro~
(Name ).
\ '16::; ~iqL.0 (Z '( L r--J
(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 installation complies with the plumbing code. of the City of
Oshkosh and the State of Wisconsin. .
This affiant understands that the Plu~bingworkauthorized
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
\\
day of
19 io
.
--~--
subscribed and sworn to before me
d
/ /-; day 191'D
. :JJ
?-,,,
ublic, Winnebag9 County, Wisconsin
My Com"~~ sion Exp1re~: ~ Ii&, ~ 1'19':L
.