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CITY OF SHKOSH N� �+�780
� � O
PERMIT APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC ❑ PLBG� SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS 3�33 �arl�v i��,�.(`� , PLAN NO.
OWNER �\CSY� �L.l�1.n.1�'
DESIGNER
USE/NATURE OF WORK � `� °�-
q-
;
;
BUILDING CONTRACTOR
Size Sq. Ft. # Rooms # Stories Height
� Foundation Class of Const. Occupancy Permit
N
HEATING CONTRACTOR �
Heat ❑ A/C ❑ Vent ❑ Fuel/System Heat Loss BTU'S 4
;
ELECTRIC CONTRACTOR
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps
Fixtures Switches Receptacles Circuits
;
�
PLUMBING CONTRACTOR �����Qm i
_BT _WH _Disp —WSoft —CBasin �s�!/ �
i
_Lav —Sh _DW —DF —San. Sewer
_WC �FDr _SP —Ur —Storm Sewer �
_Sink ��vi��li� _Eject —SS —Water ;
Other ;
D c`�
FEES: Valuation $��1��� Permit Fee Paid $ � � � ark Dedication $ �
ISSUED BY—yl�/ Date '�'y� Final/O.P. d "�� � r
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
� �. ,.,,,,.� - �- 9 �
AGENT/OWNER DATE
ADDFiESS
TELEPHONE# }
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n PLUEIDIPG PLBI�'I APPLICATION
�i.DD�ss 3 7 3 3 G , -�-�.. ��c� � s� �"° S� PER�T# _��=,
oWNEB c ic.-�`'.� y►g
,� ' �'-� Gv�
� x�rt� oF wou �-�'—
�u �r.ay a�a�t n��oa
. _ � #
;�q�g Hathtub Su Pu
I.avstc Ej ector
Toilet Water Softener
pN Dp?E IpSpEClZpp Dp1E Ki.t. Sink Drinkin Fountain
8 iak(o tiaer
W te heater Slo Sink
G ease Tra
I / / Floor Drain Local Waste
N� � � � � � `� Laundry Tu Site Drain
� Dis osal Laundr Stand i e
Dishwasher Catch Basin
** Vinlation note� on the rever�e �ide