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Home My WebLink About0152845 - Plumbing (replace tub and toilet) - VOID 0 CITY OF OSHKOSH No 152845 OSHKOSH PLUMBING PERMIT -APPLICATION AND RECORD V 0 I D ON THE WATER Job Address 1320 NEBRASKA ST _ Owner A_NCHORBANK FSB Create Date 10/09/2012 Contractor HOMEOWNER Category 413-Res-Interior(Replacement Fixtures) Plan Inspector Jerry Fabisch Bathtub 1 Clothes Wshr Classrm Sink Surgeons Sink Roof Drain - Deduct Meters Shower Lndry Tray Exam Sink Sterilizer Soda Disp Wtr Sewer Mtrs Whirlpool Sump Pump - F Prep Sink RPZ Valve - Coffee Maker Wtr Usage Mtrs Lavatory San Sump/Pump _ FlrlWst Sink Bidet Site Drain Misc. Toilet 1 Water Softner Hand Sink - Urinal Wait.St. Fixtures Kit Sink Standp Rec Lab Sink Beer Tap Ice Chest Disposal Gar Drain Plaster Sink _ Dip Well Comm Ice Maker Dishwasher Local Waste Scully Sink Drink Ftn Int GreaseTrap Floor Drain Bar Sink Sery Sink _ Wash Ftn Ext Grease Trap Hose Bibb Breakrm Sink Shamp Sink Catch Basin Eye Wash Statn Water Heater L Use/Nature SFR\Replacing tub and toilet of Work Size Material Type # Conn.Type Storm Water Parcel Id# 0304140000 Valuation $500.00 Plan Approval $0.00 Permit Fees $25.00 0 Permit Voided VOID VOID VOID Issued By Date 10/09/2012 The undersigned,in applying for a plumbing permit to install plumbing in a single family home owned and occupied as the principle residence of the undersigned,hereby acknowledges,per Wisconsin State Statutes,ss 145.06,that other individuals will not be employed to assist with the work described by this permit. If an individual will be employed to install plumbing the work involved must be covered by a permit issued to a properly licensed Master Plumber. In the performance of this work, I agree to perform all work pursuant to rules governing the described construction. Signature Date Agent/Owner Address 25 W MAIN ST MADISON WI 53703 3375 Telephone Number To schedule inspections please call the Inspection Request line at 236-5128 noting the Address, Permit Number,Type of Inspection (i.e. Footing, Service, Final,etc.),Access into Building if Secure(how do we gain entry),your Name and Phone Number. Unless specified otherwise,we will assume the project is ready at the time the request is received. Work may continue if the inspection is not performed within two business days from the time the project is ready. While the City of Oshkosh has no authority to enforce easement restrictions of which it is not a party, if you perform the work described in this permit application within an easement,the City strongly urges the permit applicant to contact the easement holder(s) and to secure any necessary approvals before starting such activity. 0 CITY OF OSHKOSH No 152845 OSHKOSH PLUMBING PERMIT -APPLICATION AND RECORD ON THE WATER Job Address 1320 NEBRASKA ST Owner ANCHORBANK FSB Create Date 10/09/2012 Contractor HOMEOWNER Category 413-Res-Interior(Replacement Fixtures) Plan Inspector Jerry Fabisch Bathtub 1 Clothes Wshr Classrm Sink Surgeons Sink Roof Drain Deduct Meters Shower Lndry Tray Exam Sink Sterilizer Soda Disp Wtr Sewer Mtrs Whirlpool Sump Pump F Prep Sink RPZ Valve Coffee Maker Wtr Usage Mtrs Lavatory San Sump/Pump Flr/Wst Sink Bidet Site Drain Misc. Toilet 1 Water Softner Hand Sink Urinal Wait.St. Fixtures Kit Sink Standp Rec Lab Sink Beer Tap Ice Chest Disposal Gar Drain Plaster Sink Dip Well Comm Ice Maker Dishwasher Local Waste Sculry Sink Drink Ftn Int GreaseTrap Floor Drain Bar Sink Sery Sink Wash Ftn Ext Grease Trap Hose Bibb Breakrm Sink Shamp Sink Catch Basin Eye Wash Statn Water Heater Use/Nature SFR\Replacing tub and toilet of Work L Size Material Type # Conn.Type Storm Water Parcel Id# Valuation $500.00 Plan Approval 0304140000 pP $0.00 Permit Fees $25.00 ❑ Permit Voided Issued By i Date 10/09/2012 The undersigned,in applying for a plumbing permit to install plumbing in a single family home owned and occupied as the principle residence of the undersigned,hereby acknowledges,per Wisconsin State Statutes,ss 145.06,that other individuals will not be employed to assist with the work described by this permit. If an individual will be employed to install plumbing the work involved must be covered by a permit issued to a properly licensed Master Plumber. In the performa t of this , I ac e to perform all work pursuant to rules governing the described construction. Signature ��1 l Date /O'4 J Agent/Owner Address 25 W MAIN ST MADISON WI 53703 3375 Telephone Number To schedule inspections please call the Inspection Request line at 236-5128 noting the Address, Permit Number,Type of Inspection(i.e. Footing,Service, Final,etc.),Access into Building if Secure(how do we gain entry),your Name and Phone Number. Unless specified otherwise,we will assume the project is ready at the time the request is received. Work may continue if the inspection is not performed within two business days from the time the project is ready. While the City of Oshkosh has no authority to enforce easement restrictions of which it is not a party, if you perform the work described in this permit application within an easement,the City strongly urges the permit applicant to contact the easement holder(s)and to secure any necessary approvals before starting such activity. City of Oshkosh Inspection Services Division PO Box 1130 ® . Oshkosh,WI 54903-1130 Phone: (920)236-5050 Fax:(920)236-5084 OJHKOJH ON THE WATER Plumbing Permit Application I hereby apply for a permit to do and install the following plumbing on the premises hereinafter described,the work to conform to the Wisconsin State Plumbing Code,in the performance of which all parties hereto agree to and are bound by said statutes. • Application(s)and fee(s)can be brought to City Hall,Room 205 or mailed to Inspection Services,PO Box 1128,Oshkosh WI 54903-1128. Commencing work without permit(s)will result in fees being doubled or$100.00 plus the normal permit fee,which ever is greater. OR Ifyou are a contractor participating in the Permit Fee Account System and have adequate funds, check here if you want this processed through your account Ft **Advisory-For applicable projects, an Electrical Installation Verification(EIV)form, signed by the Electrical Contractor or Homeowner(for installations allowed to be performed by the homeowner)must be submitted with the permit application. Applications submitted without an EIV when such is required, will not be processed for Permit Issuance and will be returned for completion. Job Address e o(i) r�C bZ. - cj, Value(Including labor and materials)6c( t •u Date)d'9'l Owner Contractor ] JSingle Family ❑Duplex ElMulti-Family ❑Rental ❑Commercial ❑Industrial Number of Fixtures: Bathtub Sump Pump Plaster Sink Roof Drain Shower San.Sump/Pump Scullery Sink Soda Disp Whirlpool Water Softener Service Sink Coffee Mkr Lavatory Standpipe Rec Shamp Sink Site Drain Toilet -I— Garage FD Surgeons Sink Waitrs Stn Kit Sink Local Waste Sterilizer Ice Chest Disposal Bar Sink RPZ Valve Comm Ice Maker Dishwasher Breakrm Sink Bidet Int Grease Trap Floor Drain Classrm Sink Urinal Ext Grease Trap Hose Bibb Exam Sink Beer Tap Eye Wash Stn Water Heater F Prep Sink Dipper Well Deduct Meter ❑Gas❑Elect❑PwrVnt Floor Sink Drink Fntn Wtr Sewer Mtr Clothes Wshr Hand Sink Wash Fntn Wtr Usage Mtr Lndry Tray Lab Sink Catch Basin Misc Fixtures Electric Contractor(for projects not requiring an EIV Form) Use/Nature of Work c - 'U OS SizefJaJ?Q Material Type # yP Conn.Type Sanitary Sewer . Storm Sewer Water Service 06/09 City of Oshkosh Division of Inspection Services 215 Church Avenue PO Box 1130 Oshkosh WI 54903-1130 DJ'}-K ..H Office(920)236-5050 ON THE WATER Fax(920)236-5084 Web:www.ci.oshkoch.wi.us AFFIDAVIT FOR PERMIT (Owner Occupied Property) State of Wisconsin, County of Winnebago, City of Oshkosh I, 64 , hereby swear and affirm under oath that: (print name) I am the owner of the property listed below, I do currently personally occupy or intend to occupy the property and I will self-perform the work. And do hereby submit an application for a permit pursuant to the Wisconsin Department of Commerce Licensing Act 28 (ss 101.147),that does not require me to be licensed by the State of Wisconsin,to perform this work at: 18ao D ..b 6 ko.4\ v� 96 STREET ADDRESS(THE"PREMISES") CITY STATE ZIP I UNDERSTAND AND WILL ABIDE BY THE FOLLOWING STIPULATIONS: 1. That I will be personally doing the work as set forth in the Permit Application and no contractor for hire will be performing any work at the Premises. 2. I understand and acknowledge that if any person other than me is determined to be performing work upon the Premises a STOP WORK order may be issued. 3. I understand and acknowledge that if I am unable to complete the work at the Premises I must hire a Wisconsin State Licensed Contractor to complete the work and obtain a permit for the remainder of work to be done. 4. I understand and acknowledge that all work must be performed in strict conformance with all applicable building and zoning codes adopted by the City of Oshkosh. 5. I understand and acknowledge that all work performed will be subject to inspection by the City of Oshkosh. 6. I agree to take full responsibility for all work completed upon and the conditions of the Premises. 7. I am certifying the above under oath and am subject to laws for perjury for any untruthful statements made herein and understand that the permit may be revoked for false statement or misrepresentation as to the material fact in the application on which the permit was based. UPON SUBMISSION,THIS AFFIDAVIT BECOMES PART OF THE ACTUAL PERMIT. ea_ku PRINTED NAME OF APPLICANT SIGNATURE OF APP ICANT jaao 1\46, c(c-A C3h}-/ tAD; V9d) STREET ADDRESS OF APPLICANT CITY STATE ZIP Sao 68' a HOME PHONE NUMBER ALTERNATE PHONE NUMBER SWORN and SUBSCRIBED to before me this day of 0G40 ,20 a at Oshkosh, County of Winnebago, and State of Wisconsin. NOTARY SEAL HERE LOSAV__�' � �'NOTARY PUBLIC Co V vlSSie-A Cep;res'. 7/(o%O!�