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� CITY OF OSHKOSH N° 30327
`' PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC ❑ PLBG� SIGN ❑ ZONING FLOOD PLAIN HEIGHT '
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ADDRESS �_��[� �T[,� PLAN NO.
OWNER /'/1//�` ln�E �� �`( C,�s-����-
DESIGNER
USE/NATURE OF WORK � r
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
, �
.
�LECTRIC CONTRACTOR
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 �/ ��d�d���_g—J
/
aN
FEES: Valuation $ ` Permit Fee Paid $ d Park Dedication $
ISSUED BY Date Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATUREnC �r�t..s.S�-- �V� . ,���-r��--- �'�� "��--
� AGENT/OWNER DATE
ADDRESS
TELEPHONE#
STATE OF WISCONSIN )
) SS
WINNEBAGO COCTN'I'Y )
�L �� c�����A-'i� � �C� t�.� , �7 �� i��
Name • Address
being first duly sw�orn on oath deposes and says that he is not
a Iicensed plumber, and that he has applied for a plumbing
permit to the Plumbing Inspector of the City of Oshkosh, to do
plumbing wcrk in a home owned and occupied by him, or a home
that is bei�g conat=ucted that is owned by him, and which will
be occupied by hicn as his home whea completed. That he is not .
building said home. for the purpose of sale.
This affidavit is cnade for the purpoae of complying with
the provisions of the plumbing code of the City of Oshkosh and
the State of Wisconain, which providea that all plumbing work
muat be done by a licensed plumber except that the plumbing work
may be doae by one who owr�s and occupies his own home prowlding
the installation complies with the plumbing code� of the City of
� ' Oshkosh aad the State of Wisconsin.
. This aggiant understands that the Plumbing w�ork authorized
+ by the pezmit applied for, must be cione only by this affiant and
that he cannot employ others who are not licensed plumbera to
assist with the work.
Dat ed this � da y of 1`��� . . 19 er,Z . �
, ,
�
�.�.,��.�,�.� J11�.
Subacribed and swc ta before me
his day o � 19��.
Nota r1 Public, Winnebago County, Wi consin
My Commission Expirea:__ ___� `�"' ����
� PLDI�ING PE�T APPLICaTION ��'� :� 7
.. 9Q 6 � � � " .2c` _ ` v �
�iDDRESS DATE FERI'�?#
OWNEH �� � LIIl�!
? ' �-s'i
NJITOBE OF WCR� 'r -�-".�
NET� REZAY BEPAIR INIERIQB
SES� � #
? �TATER Bathtub Sum Pu
Lavato Ejector
Tailet Water Softener
OIQ DA1E INSPECIZOIQ DA� ICit. Siak Drinkin Fountain
� � �9 ' ,; S iak(o ther •
�,,;�,���'� ,��__1 =' �-s'- � W te heater Slo Sink
G e se Tra
Floor Drain Local Waste
Laundry Tu Site Drain
Dis osal / Laundr Stand i e
Dishwasher Catch Basin
** Violation note• on the rever�e �ide
� ��� �A�� AL����QN
:�aaESS �' 0 6 1�/ r''' Dn� �'-�� �ys- �at�z# j �-�� 7
; OWNES PLDl�ER � �`"""a`�
NAT08E OF GTOR� � / �`- .�� �
NEi� RELAY REPAIR INTEAIOR
' AN SES1 # #
�TATER Hatl�tub Sum Pu
I.avato Ej ector
Toilet Water Softener
ON DATS INSpECTIOp DA1E Rit. Sink Drinkin Fountain
„ J. � Siak(cther
%�,,,,�%�j ;i��- `� •� � W te heater Slo Sink
� G ease Tra
Floor Drain Local Waste
Laundry Tu Site Drain
Dis osal Laundr Stand i e
Dishwasher Catch Basin
** Viclatian notes on t}se reverze �ide