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CITY OF OSHKOSH N° 42867
l� PERMIT - APPLICATION AND (RECORD
TYPE: BLDG ❑ HTG ❑ ELEC [ PLBG ❑ SIGN F-1 ZONING FLOOD PLAIN HEIGHT
ADDRESS &/Z _ PLAN NO.
OWNER
DESIGNER
USE /NATURE OF WORK
BUILDING CONTRACTOR
Size
Foundation
Sq. Ft
# Rooms
# Stories Height.
Class of Const. Occupancy Permit
HEATING CONTRACTOR
Heat ❑ A/C ❑ Vent ❑ Fuel /System Heat Loss BTU'S
ELECTRIC CONTRACTOR
Electric Serv. New ❑ Change ❑ Temp ❑ Type
Fixtures �� Switches Receptacles
PLUMBING CONTRACTOR
_BT _WH
Lav —
Sh
_WC _
FDr
Sink _
LTub
Other
Disp
DW
_SP
— Eject
Volts Amps
Circuits _
— WSoft
_ DF
— Ur
__SS
_— CBasin
--San. Sewer_
_— Storm Sewer
_— Water
FEES: Valuation 0 a ' Permit Fee Paid $ / d y �� — Park Dedication $
ISSUED BY "�'�`1^�""' Date ��s — Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE �1 �c�,r-, Q_') l 'C
AG ENT /OWNER DATE
ADDRESS
TELEPHONE N
AFFIDAVIT REZ,ATING TO SECTION 13.12 (a) OF A GENEIELU ORDINANCE
OF THE CITY OF OSEKOSH RELATING TO TEE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY )
2'
(Nam-.) Addzess
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 = day of
19.
Subscribed and sworn to before
this day of
19_.
notary Public, Winnebago County, Wisconsin
My Commission Expires: