HomeMy WebLinkAbout0003604-Electric (bathroom) � _ CITY OF OSHKOSH No _ 03604
PERMIT APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS / � ` � � � ��2r'v " PLAN NO.
OWNER :
DESIGNER
USE/NATURE OF WORK \ � �
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
ELECTRIC CONTRACTOR
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps
Fixtures � Switches �—Receptacles �� Circuits�—
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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
FEES: Valuation $ � �—Permit Fee Paid $ ` �'� Park Dedication $
ISSUED BY Date � �� r �7 Final/O.P. �/-a3- ��
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In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE �� ��
AGENT/OWNER DATE
ADDRESS O-s�
TELEPHONE
n �/ �
PERMIT NO. l � � C/ � APPL. DATE - � --�
ELEC. CONTR.
OWNER �[.�'
ADDRESS � � `� l�/ - �—
NATURE OF WORK
ELEC. SERV. NEW CHANGE
DESC. TYPE VOLTS �ypg• �
FIX' S Q� SL� �` RECEPT � CIRC' Sp� �
APPLIANCES
SIGNS �
INSP. ROUGHIN SERVICE FINAL/ -�q- l
EXT. COST 5� �i PERMIT FEE � �_ DATE PD f-/-$�
REMARKS
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AFFIDAVIT 8ELI�TING TO SECTION 13.12 {c) OF A GENEAAL ORDINANCE
OF T� CITY OF OSI�{OSH AELATING TO TF� LICENSING OF ELECTAICIANS
AND P80VIDZNG PENALTIES
3TATE OF WISCONSIN) '
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' wiNNEBAGO coUNTY ) �
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Name Address
first being duly sworn on oath, deposes and says tlzat he is not
a 2lceneed electrician in the City oP Oshkcsh and that he has
appl•ied ror an electrical permit to do electrical work in a
residence and/or au=illary buildings (intended solely for pur-
poses asaociated o�ith a residence) ahich is owned and occupied
by him, or is being ccnstructed in his name, as h2s personal
home and that said residence cr auyiliary buildings being so
wired are not to be used or erected for rental purposes or for
� resale tc present or prospective purchasers.
Affiant understands that the electrical work authorized by
the permit applied Por in connection wlth this affidavit, must
be done only by thts afPiarit and that he cannet employ others to
assist �rith the electrical work but members of his immed2ate
faoily.
Dated this day of _, 19[��
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Subscribed and sworn t before �
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this�� % � day of � � , g �.
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Notary Public, Winnebago County, Wisconstn :
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Mp Comm2ssion Eapires: �-�' �x!v ��
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