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CI OF KOSH
PERMIT - APPLICATION AND RECORD N2 16212
TYPE: BLDG ❑ HTG ❑ ELEC PLBG SIGN ZO F
❑ ❑ FLOOD PLAIN HEIGHT
ADDRESS 3 0 S ' S 1,. 0 4-e.. c ca J. D 2;v PLAN NO.
OWNER 0 rt.ofin 16 0 e-1, e
DESIGNER
USE /NATURE OF WORK J itt. F +r+ 2,.J -.r 2 evax,
•
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 M O—&. g. 14-tc.J ,.....5 0 „4 A 1 0
Electric Serv. New ❑ Change ❑ Te ❑ 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 $ /0 5 41
Permit Fee Paid $ /3 — Park Dedication $
ISSUED BY Date ! — 6 — T7 Final /O.P. // ' ' — 8 p
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE �y .s��✓y„���A ✓* _ ///4189
AGENT /OWNER DA
ADDRESS
TELEPHONE #
PERMIT NO . l e --` APPL . DATE //- 4 - P7
ELEC. CONTR. ')2/ a-1 AC ` - ` -r-g---
OWNER DUB /
ADDRESS 305 C
NATURE OF WORK @� r' +�
ZLEC. SERV. NEW j��-- CHANGE TEMP.
DESC. TYPE VOLTS AMPS
FIX'S SW ' S (2 RECEPT'S CIRC'S X
APPLIANCES
SIGNS
INSP, ROUGHIN SERVICE b FINAL // `e-17
EST. COST / 2 — PERMIT FEE /s DATE PD .i/ - 6 -K7
REMARKS
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