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CITY OF OSHKOSH N 45695
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC
x. PLBG ❑ S IGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS 42. d r D ; ®.-. PLAN NO.
OWNER Xt-L' ,Ie 6,&
DESIGNER
USE/NATURE OF WORK ` - 01-4, 0‹ ief�ivY/t I
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 CONTRACTORda '20.--r►-. •
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps
Fixtures `---- Switches Receptacles ✓ Circuits
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 CO . c Permit Fee Paid $ / 0, 0 0 Park Dedication $
ISSUED BY 4�C-(A`— Date 1 0 1 Final /O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE A N. SC G` 2 7 / � S-
AGENT /OWNER / DATE
ADDRESS
TELEPHONE 0
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)
J c4,4/647k 21I /fob( %
(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 purposes 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 21 day of "T e , 19j
Subscribed and sworn to before
this day of , 19_.
Notary Public, Winnebago County, Wisconsin
My Commission Expires:
7/(74'r
PERMIT NO. . APPL. DATE
ELEC. CONTR. Aeryze.4
OWNER kt.t/L
2 3 3 3 6 r/
ADDRESS 3-60 0 ill f ( I ✓.cam
NATURE OF WORK
ELEC. SERV. NEW CHANGE TEMP .
DESC. TYPE VOLTS AIDS
FIX'S SW'S RECEPT'S CIRC'S
APPLIANCES
SIGNS 7 le- SERVICE FINAL
INSP. ROUGHIN //
EST. COST PERMIT FEE DATE PD.
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