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/� CITY OF OSHKOSH N° 05267
`' PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG � ELEC ❑ PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT ;
ADDRESS L��CC' .sL�,S� � PLAN NO.
OWNER �IC�/7TIGDC`;� I
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DESIGNER
USE/NATURE OF WORK �
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BUILDING CONTRACTOR
Size Sq. Ft. # Rooms # Stories Height
Foundation Class of Const. Occupancy Permit
HEATING CONTRACTOR �' — � 1-°L�'
Heat ❑ A/C �Vent ❑ Fuel/System Heat Loss��C /�,S � BTU'S dh
ELECTRIC CONTRACTOR
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps t
Fixtures Switches Receptacles Circuits
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PLUMBING CONTRACTOR
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� —BT _WH Disp _WSoft —CBasin
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Lav _Sh DW DF San. Sewer
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3 —WC —FDr —SP Ur —Storm Sewer
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—Sink _LTub _Eject SS —Water
Other
FEES: Valuation $ ��� �� Permit Fee Paid $ ,��� �� Park Dedication $
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ISSUED BY � Date Final/O.P. �C� '�f��? `
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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 1
AGENT/OWNER DAT
ADDRESS
TELEPHONE#