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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 )
4 / 0/50 / /c-
(Na (Address)
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.
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 6r day of 4,�y , 19 .
Subscribed and sworn to before
this day of ‘2d) , 19a.
g l,t0fie rr)6,1>a<
Notary Public, Winnebago County, Wisconsin
My Commission Expires: (W /o&
PERMIT NO. //c:. �G _ APPL. DATE 3 J CS — v 5
/ `/
ELEC. CONTR. '
OWNER
ADDRESS / 1 7 1 / g —
NATURE OF WORK
ELEC. SERV. NEW CHANGE TEMP.
DESC. TYPE jU , )--14 -06 VOLTS /> '{ U
8 d AMPS
FIX'S b- SW' S y RECEPT' '�" CIRC S "
APPLIANCES
, tom
SIGNS
INSP. ROUGHI' SERVICE FINAL
EST. COST ► �nOQI PERMIT FE o 2 - PD 85
REMARKS