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AFFIDAVIT 1ELATING 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 )
c.1 (/,[~,c/ litJ r~i~~~~- ~ , oC ~P~~°f-.SQrt J`]'L~
Name Address
first being duly sworn on oath, deposes and says that he is not
a licensed electrician in the City: of Oshkosh and that he has
applied for an electrical permit to do electrical work in a
residence and/or auxiliary buildings (intended solely for pur-
poses associated with a residence) which is owned and occupied
by him, or is being constructed in his name, as his personal
home and that said residence or auxiliary 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 in connection with this affidavit, must
be done only by this affiant and that he cannot employ others to
assist with the electrical work but members of his immediate
family.
Dated this ._~ day of Pbf ~~rr~~ 19 ~~
Subscribed and sworn to before
thi s ~~~ day of / , 19~.
Notary Public, Winnebago County ldigconsin
MY COp/-MI yS~OtV E'~CPIRES
My Commission Expires: ~u--Y 20, i9si
Permit No. /~ ~ / D e ~- ~ - ? ~
Contractor- ~,, ~,~~ o „ ~,
Owner
Address ~,Z ~
New Service
Furnace
Electric Sign
Air Conditioner
Gas Pumps ~.
Fixtures
Switches
Receptacles ~
Circuits /- is- ~
Service Cleared
O.K, to Clcse
Final Inspection -- - .~ d!
Change Service
Temp. Service
Range
Water Heater __
Garbage Disposal
Dishwasher
Dryer
Fan or Blower
Motors
Date Issued ~ -~.
Remarks : (o U . ~