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CITY OF OSHKOSH N° 35116
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC X PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS /1/ 5 PLAN NO.
OWNER C J` e—
DESIGNER ' - /
USE /NATURE OF WORK t<J 1$
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 ./
Electric Serv./�New N Change ❑ Temp ❑ Type, Volts 2 Amps L�1
Fixtures v< Switches 0 ( Receptacles K_ Circuits K 3's/L-
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 $ _,- Permit Fee Paid $ F:5 Park Dedication $
ISSUED BY Date �/ ", Final /O.P. /1. /7.93
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE 7/%2/177 C�3
/ AGENT /OWNER '
ADDRESS ) //S' L a " - cA",Q. — Avg 9.)- 6-/o70
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 )
csse_ G e rfi r l / /s� Z a. o. r
(Name) (Addr6s s )
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.
Afflant understands that the electrical work authorized by
the permit applied for in connection with 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 - 7 day of 3 0 1 y , 19 33.
, ,),elitAL .„,-1.#___
Subscribed and sworn to before
this day of , 19.
4/
ff, .'
Notary _ublic, Winnebago County, Wisconsin
My Commission Expires: 2 )191,
7 4 °7
PERMIT NO. APP DATE — 2 7
ELEC. CONTR. // �
OWNER
/ I
ADDRESS l // 5 - - •
NA RE OF WORK
g 1._
ELEC. SERV. NEW D"- CHANGE MP
DESC. TYPE 3 — w -- v VOLTS I zy �O AMP O '
,FIX'S SW'S y RECEPT' Q� CIRC'
APPLIANCES
SIGNS ✓ �`
INSP. ROUGHEN 03A7, SERVICE FIN /7/4
E . COS 000 ----- PERMIT FE SS' = DATE PD. -
REMARKS, 'cf. ,71
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