HomeMy WebLinkAbout0040190-Electric (service change)
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CITY OF OSHKOSH
PERMIT - APPLICATION AND RECORD
((73 <f
Ng 40190
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ADDRESS
PLAN NO.
OWNER
DESIGNER
USE/NATURE OF WORK
BUILDING CONTRACTOR
Size
Sq. Ft.
# Rooms
# Stories
Height
Occupancy Permit
Foundation
Class of Const.
HEATING CONTRACTOR
Heat 0 NC D Vent D Fuel/System
Heat Loss
BTU'S
ELECTRIC CONTRACTOR cft.dY?~
Electric Servo New D Change~ Temp D Type~ Volt~W AmpsL()b
Fixtures Switches Receptacles Circuits
PLUMBING CONTRACTOR
_BT _WH _Disp _ WSoft _ CBasin
_Lav _Sh _OW _OF _ San. Sewer
_WC _FOr _SP _Ur _ Storm Sewer
_Sink _LTub _ Eject _SS _ Water
Other
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FEES: Valuation $ d~tJ.cJ a Permit Fee Paid $ r{:CJ C) j
ISSUED BY ~ d<<U-<<""'~ Date
Park Dedication $
Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE~~ ~
AGENT/OWNER DATE
ADDRESS
TELEPHONE #
P'
,
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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 PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY )
~~ F (Z //1n4-/
Name
. Sl3/h d-t ~~-i spl (!1%1..~
Address
first being duly sworn on oath, deposes and says that he 1s not
a licensed electrician in the City of Oshkosh and that he has
applied for an electrical permit to do electr1cal work 1n a
residence and/or auxiliary buildings (intended solely for pur-
poses associated w1th a residence) which 1s owned and occupied
by him, or is be1ng constructed 1n his name, as h1s personal
home and that said residence or auxiliary buildings being so
wired are not to be used or erected t:or rental purposes or for
resale to present or prospect1ve purchasers.
Aff1ant understands that the electrical work author1zed by
the perm1t applied for 1n connect10n w1th this aff1dav1t, must
be done only by th1s.aft:iant arid that he cannot employ others to
assist w1th the electrical work but members of his 1mmediate
fam1ly.
Dated this
~7
day of
Vc,,--1/
, 1913t
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Subscribed and sworn to before
th1s
day of
, 19_-
Notary Pub11c, W1nnebago County, W1scons1n
My Commission Exp1res:
~RMIT NO. 'fo 19 ()
ELEC. CONTR. (),.l-Y1-t.A
OWNER ~./)~
~~ESS 9l-7 ;4~
NATURE OF WORK
f
. AEPL. DATE
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fo/Z7~ ';I
. ELEC. SERV.
~ESC. TYPE
FIX'S
~PLIANCES
SI'GNS
~SP. ROUGHIN
EST. COST
REMARKS
NEW
0111
SW'S
VOLTS . W
RECEPT'S
TEME.
~S
CIRC'S
.... .~
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F IN ALAlOJ/e
DATE PD.
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SERVICE t,/zI'A <F
PERMIT FEE' f
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