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_CITY OF OSHKOSH N° 19370
PERMIT APPLICATION AND RECORD
TYPE: BLDG ^ HTG ^ ELEC PLBG ^ SIGN ^ ZONING FLOOD PLAIN HEIGHT
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ADDRESS ~ ~~~~ `~ i n C.~/ '" PLAN NO.
OWNER
DES
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I IQC/1~IAT1 ~nr ~r ui~rw ~ ~s/ / i. A /T1 / i~.~ /1 ~_.~i ~ A
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BUILDING CONTRACTOR
Size Sq. Ft. # R t
Foundation oms # Stories Height
Class of Const. Occupancy Permit
HEATING CONTRACTOR
Heat ^ A/C ^ Vent ^ Fuel/System Heat Loss BTU'S
ELECTRIC CONTRACTOR >
Electric Serv. Ne Change ^ Temp ^
Fixtures ~ Switches ~_ Rece Type Volts 'Amps o2d0
ptacles ~ Circuits ~_
PLUMBING CONTRACTOR
BT WH Disp
- Lav Sh _ DW
WC _ FDr _ SP
-Sink LTub -Eject
Other WSoft CBasin
DF -San. Sewer
_ Ur -Storm Sewer
SS -Water
p~
FEES: Valuation $ j ~ ~ ~~ Permit Fee P
ISSUED B
aid $ ~~ ~~ Park Dedication $
Date ~~~~ Final/O. P. ~~ =~- /O
In the performance of this work I agree to perform all wor
~, e
SIGNATURE
AGENT/OWNER
ADDRESS ! .Z :~ ~ // f(f~ ~ ~CG US/IKf S' t pursuant to rules governing the described construction.
'7 -~,Z `~~
DATE
~ LG ~G JT/~G~~ ,~3~--gC~ Q
TELEPHONE #
AFFIDAVIT BEI.ATING TO SECTION 13.12 (c) OF A GENERAL ORDINANCE
OF THE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND P80VIDING PENALTIES
STATE OF WISCONSIN)
SS
WINNEHAGO COUNTY ) .
Address
first being duly sworn on oath, deposes and says that he is not
a 2lcensed electrialan in the City of Oshkosh and that he has
applied for an electrical permit to do electrical xork in a
residence and/or av=iliary buildings (intended solely for pur-
poses associated xith a residence) xhich is owned and occupied
by him, or is being constructed in his name, as his personal
home and that said residenae or auxiliary buildings being so
aired are not to be used orerected for rental purposes or for
resale to present or prospecti4e purchasers.
ASfiant understands that the electrical xork authorized by
the permit applied for in connectioa with this affidavit, must
be done only by this at'fiant and that he aanaot employ others to
assist xith the electrical xork but members of his immediate
family.
Dated this .Z ~`~ day of 1 ~ 1.
----___., 9.ZS~
Subscribed and sworn to befo~'re
~L
this /~-- day of _, 19~,. --
Nota~ ~~iblic, Winneb
="Y ago Couaty, Wisconsin
My Commission Expires:
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