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CITY OF OSHKOSH N° 32270
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC,' PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS / V /7 — PLAN NO.
OWNER R i,41t
DESIGNER
USE /NATURE OF WORK
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 ❑ Change El Temp 11] Type Volts Amps
1:<
" -- Switches receptacles Lk Circuits IC)'S (53----
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
40e, �
f i
FEES: Valuation $ `� permit Fee Paid $ / Park Dedication $
ISSUED BY / :,-/../ – vv
Date / — % Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE 6 , cf /- 4'" 93
Q AGENT / �i � � } `-� /�+ DATE
ADDRESv� /U pcnAr t.DJ „ 0.s. `'k"'�1I tor r- y'C ` e / 3 S v il�1
TELEPHONE #
AFFIDAVIT RELATING TO SECTION 13.12 (c) OF A GENERAL ORDINANCE
OF TEE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSIN)
SS
WINNEBAGO COUNTY )
45S feretida 1_14se /0)0 vd_ 3 )9-1s -Powers S+ 6
(Name) (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 }h day of , \all" ar y , 19q3.
L eZZ/I .
Subscribed and sworn to before
this � day of , 1973 .
Notary •ublic, Winnebago County, Wisconsin
I
My Commission Expires: 1
PERMIT NO . - _ . APP . DATE /
E C. CONTR.
OWNER / ' // Mpt.d_e_Ze--e,-v.
ADDRESS ! ,V L o � LZ J f
NATURE OF WORK
ELEC. SERV. NEW CHANGE TEMP .
DESC. 'E VOLTS AMPS
F X' SW'S R_CEPT' I_ C RC' 4 °'
APPLIANCES
S I'GNS
INSP . ROUGHIN SERVICE FINAL Ate
EST. COST Od PERMIT FEE /5 ■ DATE PD J " 5
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