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Division of Inspection Services
(1-1--1111;) 215 Church Avenue
P.O. Box 1130
0 /HKOM Oshkosh, WI 54903-1130
Fax # (920) 236 -5084
ON 1 H WA1LR
Phone (920) 236 -5048
HVAC PERMIT APPLICATION
All fields /information after bold categories must be provided.
Incomplete applications will not be processed.
DATE I — IU - 0 I
JOB ADDRESS p2I /UAUUO Av
OWNER E — — b I I4.<Vf L..
CONTRACTOR Nt 2 �t _.f�-A l C L
CIRCLE ALL APPLICABLE
USE CATEGORY SINGLE FAMILY DUPLEX MULTI- FAMILY 10MMERCIAL) INDUSTRIAL
FUEL �AS) OIL ELECTRIC SOLAR SOLID //
SYSTEM NEW EPLAC OTHER
•
TYPE FORCED AIR ) RADIANT STEAM A/C VENT
ELECTRIC HOT WATER SUPPL. CON. BURNER
IS CHIMNEY BEING LINED LINER SIZE MANUFACTURER
Note: All chimneys shall be sized per the BTU's being vented.
CHIMNEY TYPE CHIMNEY A CHIMNEY B DIRECT VENT OTHER
HEAT LOSS AS APPROVED EXISTING NOT APPLICABLE
BTU RATE AS PER PLAN VARIABLE OTHER VALUE
NATURE OF WORK: Ke - n l A `S
VALUE (Including labor and materials) $ 1
•
ELECTRICAL CafiT :.AC OR bet Z
Electrical installation of new /replacement equipment shall be done by licensed
contractors.
Valuation Fees
$ 0 to $1,000.00 ._...._._.. .._...._._._._._...._._...._... _._...._._._._... .$ 2 0 .0 0
$1,000.01 to $10,000.00--..... _.._._...._._._._........_ $20.00 for first
$1,000.00 plus $1.50 per $100.00 valuation or part thereof
$10,000.01 to $25,000.00 $155.00 for first
$10,000.00 plus $1.00 per $100.00 valuation or part thereof
Over$ 2 5, 0 0 0. 0 0.._._..--_...... ..._.......... _.......... _._._._.._._...._ ............ .__.._.... _._._....... -_- ...... _. $305.00 plus $0.50
per $100.00 valuation or part thereof
• Submit payment with application. Failure to pay within 30 days will result in
fees being doubled or $100.00 plus the normal permit fee, which ever is
greater.
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Electric Installation Verification
i - i i VV e) ',3eez Electric roc
i ti'. 12th Cosh cish WI 54902
have :peen contractted to perform clecti thstallatior work for Marx HeRti_,g &C poling,
the following ad .ress. 21 Waugoo Avenue
flit nature of the work consists of (Check One o- Describe the Nature of Work)
i Reconnect; on or ri v circuit for replacement Heating Plant and/or AT Condenser
Rec nnectio n ::ir new cii: uit for replacement Electric Waxer Heatei
E Rec.oslu ectic >r: of the Service Entrance C'ahie. Meter Box. alterations to receptacles and
lighting fixtures due to siding ' soffit instaiiation Note: New Service Entrance Cables
will require a separate permit.
_l Reconnection or nee c rcuit for other pe i ianent `' wired appliances ' tix
Other
The ,. c4l'se of this work is S400 0
I hereb, vier . tw.is work will be per-formed by an err l:i. : :.. ee of this company and further verify the
reconnect: rn ,.rista?'atikkiri will he done in compliance with manufacturer and Electric code
requirements
i_ i. Gan: B u . er .Y 097 10/01
(Si` nature ef)C um pa :i' Officer)
j
1.