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0 6363
CITY OF OSHKOSH N- 4
� PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC � PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT ;
ADDRESS � � � PLAN NO.
OWNER—�rv`�' .C���e-c%GG!//
DESIGNER
USE/NATURE OF WORK lQ�� �---
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 ❑ Typ� �' Volts 1� Amp��
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
FEES: Valuation $ �� �'`�� Permit Fee Paid $ Sr�•� � Park Dedication $
ISSUED BY �� Date 7�� L/� S� Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
AGENT/OWNER DATE
ADDRESS TELEPHONE N
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PERMIT NO. �3�p 3 . APPL. DATE �
ELEC. CONTR. �i,,��r�.A...o,�_
OWNER �/� ���F'���- �
.
ADDRESS �am � ��.,,�,�-r.,,/� �,c./�c�-
NATURE OF WORK `
.
EC. SERV. CHANGE TEMP.
DESC. TYPE VOLTS AMPS'Zov
FIX' S SW'S RECEPT' S CIRC' S
APPLIANCES
S I�GNS � �
ZNSP. ROUGH N SERVICE 7 ' FINAL
EST. COST?.�o p PERMIT F'EE o DATE PD. �"
REMARKS
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