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CITY OF OSHKOSH N! 47289
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC' PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS /1 fil
PLAN NO.
OWNER i , G .. //
DESIGNER
USE /NATURE OF WORK Guvu A-A-AA �P� "�4 % i'.I Atx-A--
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 1t vt to
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps
Fixtures Switches 3 Receptacles Circuits 1 -----
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
a /
FEES: Valuation 1-5 . °' o / Permit Fee Paid $ Park Dedication $
ISSUED BY Date 9 7 2 17 51 1 Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE )(
//% AGENT /OWNER DATE
ADDRESS
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)
,Z, 1- Z.—. z-(-/ / I /
(N. (Address)
first being du y sworn on oath, deposes and says that he is not a licensed electrician in the City of
Oshkosh and at he has applied for an electrical permit to do electrical work in a residence
and/or auxili. buildings (intended solely for purposes associated with a residence) which is
owned and o cupied by him, or is being constructed in his name, as his personal home and that
said residen - • a 'Hazy buildings being so wired are not to be used or erected for rental
purposes or/ re-. e to present or prospective purchasers.
• y • . derstands that the electrical work authorized by the permit applied for in
connec , th 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.
f
Dated this Z ( day of 1 Sr-
1 41110rw — - '-' ••-
- --,,, 44 4. 41L%i‘
Subsc - . ed and sworn to before
this day of , 19_.
Notary Public, Winnebago County, Wisconsin
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