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PERMIT NO. � �� APPL. DATE �~ � �` O�
ELEC. CONTR. �'
OWNER Y� �--�,l�2-J
ADDRESS � 1 ,} � � L(/ `x�� '
NATURE OF WORK
I
� ELEC. SERV. NEW CHANGE � TEMP.
� T1ESC. TYPE VOLTS AMPS
FIX'S SW' S p� RECEPT' S _ CIRC' S
APPLIANCES
SIGNS
INSP. ROUGH N SERVICE rINAL
EST; COST � I?ERMIT FEE SO='�"DATE PD,/:Z/-135
R_EMARKS
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AFFIDAVIT FiELATING TO SECTION 13.12 (c ) OP A GENEAA.L ORDINANCE
OF THE CITY OF OSI�OSH AELATING TO THE LICENSING OF ELECZ'F3ICIANS
AND PROVIDING PENALTIES �
�
~ � STATE OF WISCONSIN) �
' ) SS �
WINNEBAGO COUNTY ) � �
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'�' � v ( �'7�-4 �� �S (�o; '
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Name Address
;
f2rst being duly sworn on oath, deposes and says that he is not r
a liaensed electrician in the City of Oshkosh and that he has �
applied 2'or an electrical permit to do electrical work in a
residenae and/or auxiliarq buildings (intended solely for pur- �
poses asaociated 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. E
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
faoily.
. � ;
Dated this o��5� day of _ � , 19 8,� `
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Subscribed and sworn to before
this �; day of , 19�.
x
� � ��„��'�I�h �iti� � � V��LwX�l t.
' •Notary Pnbllc, WSnnebago County, Wisconsin '
My Commission Expires: �� �a ��jo
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