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N° 48248 CITY OF OSHKOSH
PERMIT APPLICATION AND RECORD
TYPE: BLDG HTG ELEC
I( PLBG SIGN ZONING FLOOD PLAIN HEIGHT
ADDRESS /Z 9 7- U� C.G.( A l PLAN NO.
OWNER "Jti� �L
/3 [iC v
DESIGNER r
USE /NATURE OF WORK zLB�'r 41,-6(
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 o[.��Ll
Ele Serv. New Change Temp Type Volts Amps
Fixtures Switches Receptacles Circuits
PLUMBING CONTRACTOR
BT WH Disp WSoft CBasin
Lay Sh DW DF San. Sewer
WC FDr SP Ur Storm Sewer
Sink LTub Eject SS Water
Other
FEES: Valuation 2-10.0 c3 t Permit Fee Paid Park Dedication
ISSUED BY A� Date //i f f Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE X 4/0 t/u) ii
AGENT /OWNER DATE
ADDRESS L
TELEPHONE
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)
kalio Ia-9� k.)he1 1‘,1,1.4 t,J (Name (Addres)
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 purposes 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 19_
l•• 1
Subscribed and sworn to before
this day of 19_.
Notary Public, Winnebago County, Wisconsin
My Commission Expires: