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CITY OF OSHKOSH N2
PERMIT - APPLICATION AND RECORD
28582
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(U-vJ J1~hA
ADDRESS
PLAN NO.
OWNER
DESIGNER
USE/NATURE OF WORK "j:/~
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
BTU'S
ELECTRIC CONTRACTOR () I~
Electric Servo New 0 Change 0 Temp 0
Type _ Volts _ Amps_
Fixtures
Switches Receptacles
50A, ~ f?~
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
ISSUED BY
/
IO,f)~ /
~l~.9~
Park Dedication $
Final/O.P.
Date
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE ~~
/~3 19 1k./'r 1.~Ch, ,,-9f
$a) /C/d-
. DATE'
ADDRESS
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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 )
Ra berT .k).
( Name )
to ii~s
13/9 1rr:!,07'. ~ f
Address)
8<lkos.l: 0L
'"
,
f1rst be1ng duly sworn on oath, deposes and says that he 1s not
a 110ensed electr1c1an 1n the C1ty of Oshkosh and that he has
app11ed for an eleotrical perm1t to do electr1cal work 1n a
residence and/or auxi11ary bu1ldings (1ntended solely for pur-
poses assoc1ated w1th a residence) which is owned and occupied
oy him, or is be1ng constructed 1n his name, as his personal
home and that said res1dence or aux1liary buildings being so
Wired are not to be used or erected for rental purposes or for
resale to present or prospective purchasers.
Affiant understands that the electrical work authorized by
the permit applied for 1n connection with this affidavit, must
be done only by this aff1ant and that he cannot employ others to
ass1st with the electr1cal work but members of his immediate
family.
~
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Dated this
15 7t... day
of rY1 d
-#J~
,199::J-
-
Subscribed and sworn to before
this 16.dP,; day of
~m L~
Notary P bl1e, W1nnebago County, W1sconsin
My Comm1ss1on Exp1res: r ~ (If 'p-
~
, 19~.
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itEc. SERVo
C. TYPE
FIX'S
APPLIANCES
PERMIT NO. :2 :iTS?) ~P . DATE r ~ IS - '7
ELEC. C NTR. /
(JO ~~[;di?
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..~. ~/{?~
CHANGE TEMP .
VOLTS AMPS ,
RECEPT' CIRC'S
OWNER
ADDRESS
NATURE OF WORK
~~
NEW
SW'S
SI"GNS
INSP. ROUGHIN
EST. COST /OO~
REMARKS
SERVICE FINAL
PERMIT FEE /~:::::::- DATE ~-I5'-r..2.
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