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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
00935
~~P_E~ _ _ ~L~~ _C: _ ~T~ _ C? _ ~~E? _~ ~~B~ _ C? _ ~I~~ _~ _ ~O_N~N~ _ _ _ _ _ _ _F~~~D_ ~L~I~ _ _ _ _ _ _ ~~I~~T_ _ _ _ _
::NRE:SS ~ ~ JY~ PLAN NO
DESIGNER
USE/NATURE OF WORK
~~~
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
ELECTRIC CONTRACTOR ,/ij ,
Electric Servo New 0 Change 0 Temp 0 Type _ Volts_
Fixtures ~- Switches ~"'-RecePtacles ~-Circuits
BTU'S
Amps_
~.~
PLUMBING CONTRACTOR
_WC
_FDr
_ LTub
_Ur
_ CBasin
_ San. Sewer
_ Storm Sewer
_ Water
--'-- BT
_WH
_Sh
_Disp
_DW
_SP
_ WSoft
_DF
_Lav
_Sink
Other
_ Eject
_SS
,.
Permit Fee Paid $
Date
/
/ ;;Z '!5:-- .;
J)-/:?- -?6
Park Dedication $
Final/O.P. Lj - I s- - & t.
ISSUED BY
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE6;""~ ~~
GENT/OWNER
ADDRESS d. '\- ~C) ~--... ~~.
~-\~-~\a
DATE
b~~~
~3~ - \..\\:J<i"d--
TELEPHONE #
-."
AFFIDAVIT RELATING TO SECTION 13.12 (c) OF A GENERAL ORDINANCE
OF TEE CITY OF OSBKOSB RELATING TO TEE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY )
'.
"
,=*e.. \l ~ ~ R. '> \....\ ~ 0-.0... <se.. ~ '("
(Name )
J
~'-\~C:l \\o-:'rc\.\\~~Y"\. ~\.. a~h\C<J~"
(Address)
flrst belng duly sworn on oath, deposes and says that he 1s not
a 1.1censed electrician in the City or -Oshkosh and that he tuls
applied tor an electrical permit to do electr1cal work ln a
res1dence and/or auxiliary buildings (intended .solely for pur-
poses assoc1ated with a residence) which 1s owned and occup1ed
bY' him, or is being constructed in his name, as h1s personal
home and that sa1d residence or auxiliarY' bu1ldings be1ng so
wired are not to be used or erected for rentEi,l purposes or for
resale to present orprospect1ve purchasers.
At"tiant understands that the electr1cal work author1zed bY'
the perm1t app11ed for 1n connect1on w1th this aff1dav1t, must
be done only by this aff1ant and that he cannot employ others to
assist with the electrical work but members of h1s immediate
family.
Dated this
, a. ..u--,.
day of
~~
~~~
, 19'bb.
~~
Subsoribed and sworn to before
t~s /8 ~ d31 ot c20~
):-lihVo~ 1-. ~~~
, 19&.
Notary Public, Wlnnebago County, Wisconsin
My Commiss1on Exp1res: 8/5 !qO
.t
Eme. SERVo NEW caA!!GE
p~se. TYPE VOLTS
!X'S!?Z-- S JV k REcEPT'S ''>
;;;ISA!!cES. ~. ~
INSP. ROUGll~~'l1" SERVIcE ' FINAt!S'i~- {,
~~~ST .1& ~m~ PERMIT FEE>,20~ PATE pp__l~_-
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PATE t5. ~/ 2 .j? b
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PERMIT NO.O" () '1.1 5
E EC. CONTR.
~/O\ftlER
. ADDRESS
NATURE OF WORK
TEME.
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C'IRC'S