HomeMy WebLinkAbout0000045-Electric (service change) � _ CITY OF OSHKOSH No _ 0004�
PERMIT APPLICATION AND RECORD
TYPE: -BLDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS �� � / � • PLAN NO.
�
OWNER C� �
DESIGNER
, �
USE/NATURE OF WORK ��'e' �
� (p 3 _ /O
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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�VAmps��
Fixtures � Switches Receptacles Circuits �G/`-'`J
.
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
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FEES: Valuation $ � f Permit Fee Paid $� �✓� Park Dedication $ `
ISSUED BY Date �� �~�� Final/O.P. 4''���a � �•
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In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
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SIGNATURE L � l ��
AGENT/OWNER DATE
ADDRESS 0 d`'����d ��
TELEPHONE 8
PERMIT NO. �� � Q �� . APPL. DP.TE � � � ~ ��
ELEC. CONTR.
� OWNER .�� t°� � �
ADDRES� �- �
NATURE OF WORK �
ELEC. 'SERV. NEW CHANGE TENIP.
DESC. TYPE - O - � VOLTS !1-C� �'-10 AMPS �
FIX' S SW' S RECEPT' CIRC'S
APPLIANCES
SIGNS
INSP. ROUGHIN SERVICE FINAL !f
EST. COST � PERMIT FEE 5 ---�ATE PD. - ` �o
REMARKS
AFFIDAVIT F�ELATING TO SECTION 13.12 (c ) OF A GENEAAL 08DINANCE
OF T� CITY OF OS�OSH AELATING TO TI� LICENSING OF ELECTFiICIANS
AND PAOVIDING PENALTIES
STATE OF WISCONSIN) '
) SS
_ WINNEBAGO COUNTY ) '
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��sG✓ � 0 tiJ �'� ,
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Name Address
Pirst being duly sworn on oath, deposes and says that he is not
a liaensed electrician in the City of Oshkash and that he has
appl�ied for an electrical permit to do electrical work in a
residenae and/or auailiary buildings (intended solely for pur-
poses associated with a residence) which is owned and occupied
by him, or is being constrvcted in his name, as his personal
home and that said residence or auxiliarq buildings being so
wired are not to be used cr erected Por rental purposes or for
� resale to present or prospective purcha.sers. :
AfPiant understands that the electrical work authorized by
the permit applied Por in connection with this affldavit, must
be done only by th2s affiant and that he cannot employ others to
assist with the electrical work but members of his immediate
faoily.
Dated this � day of �(i�✓t , 19 D �
.
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Subscribed and sworn to before
tnis _� �y of J�,<<� , 19 ��.
'�� � J� C+tic��e�a,�..
Notary �Pu ic, Winnebago County, Wisconsin
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My Commission Expires: �- � a'�S`1