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N°- 44184
~ CITY OF OSHKOSH
4' PERMIT -APPLICATION AND RECORD
TYPE: BLDG ^ HTG ^ ELEC ~_ PLBG ^ SIGN ^ ZONING FLOOD PLAIN HEIGHT
ADDRESS ~S O 3 ~ // ~1 PLAN NO.
~.
OWNER
DESIGNER
BUILDING CONTRACTOR
Size Sq. Ft. # Rooms # Stories Height
Foundation Class of Const. Occupancy Permit
HEATING CONTRACTOR
Heat ^ A/C ^ Vent ^ Fuel/System Heat Loss BTU'S
ELECTRIC CONTRACTOR ~~!~??t~ . //3 ~U/ S~gO
Electric Serv. New ^ Change ^ Temp ^ Type Volts Amps
Fixtures ~ Switches -~ Receptacles / Circuits
PLUMBING CONTRACTOR
BT - WH _ Disp _ WSoft - CBasin
Lav _ Sh _ DW _ DF _ San. Sewer_
- WC _ FDr _ SP _ Ur -Storm Sewer
-Sink _ LTub _ Eject - SS -Water
Other
FEES: Valuation $ 2DD ~ 9 ~
ISSUED BY
Permit Fee Paid $ ~ ~ ~ ~ ° J Park Dedication $
~ Date ~~-/ S S~ Final/O.P.
In the pertormance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
ADDRESS
~~ ~CJ~ I ~ 1~~
DATE
TELEPHONE #
AFFIDAVIT HEZ~TING TO SECTION 13.12 (c) OP A GENE.~iAL ORDINANCE
OF TIC CITY OF OSHKOSH AFT•eTING TO THE LICENSING OF ELrCTAICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
SS
WINNEBAGO COUNTY )
~-n- ~ S o 3 `~
ame dress
first being duly sworn on oath, deposes and says that he is not
a 2lcensed 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 yr au~ciliary buildings being so
wired are not to be used or erected for rental purposes or for
resale to present or prospecti4e purchasers.
Afflant understands that the electrical work authorized by
the permit applied For in connection •ai th this affidavit, must
be done only by this afflant and that he cannot employ others to
assist with the electrical work but' members of his immediate
family.
Dated this Z_ ~y of ~~~tGh
19~~
Subscribed and sworn to before
this day of , 19_•
Notary Public, Winnebago County, Ldisconsin
Mp Commission Expires: