HomeMy WebLinkAbout0022774-Electric (addition) � CITY OF OSHKOSH N° 22774
`' PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS ��v ^ PLAN NO.
OWNER �
.
DESIGNER
�
c /�/� ,
USE/NATURE OF WORK L���O (������!Z�
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 ❑ ype Volts Amps
' Fixtures �witches , eptacles �� `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
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FEES: Valuation $ ���rmit Fee Paid $ �� `—~ Park Dedication $
ISSUED BY Date �f �/ f Final/O.P. T,a-�a - C>i �
In the performance of this work I agree to perform all work pursuan o rules governing the described construction.
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SIGNATURE � G�� • � , �/!
� AGENT/OWNER DATE
ADDRESS �� � ����'� �3�J �O / O :
TELEPHONE#
AFFIDAVIT AELATING TO SECTION 13.12 (c ) OP A GENEAAL 08DINANCE
OF T� CITY OF OS�LOSH &ELATING TO TI� LICENSING OF ELECTfiICIANS
AND PHOVIDING PENALTIES
� 3TATE OF WISCONSIN)
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WINNEHAGO COUNTY )
Jv � n �) - 1� ���, 1 �ld S�o�- Avc�
,
Name Address
t'irst being duly sworn on oath, deposes and says that he is not
a 3lcensed electrlcian in the City oP Oshkosh and that he has
appl•Sed for ars electrical permit to do electrical work in a
residenae and/or au=Sliary buildings (intended solely for pur-
poses associated xith a residence) �hich is owned and occupied
by him, or is being ccnstructed in his name, as his perscnal
home and that said residence or au=Sliary buildings being so
a�ired are not to be used or erected 2'or rental purposes or for
� resale to present or prospecti4e purchasers.
APfiant understands that the eleotrical work authorized by
the permit applied for 3a connection w3th thls affidavit , must
be done only by this at'fiant and that he cannot employ others to
assist �rith the electrical work but members of his immediate
Panily.
Dated this /� day of � �'� � , �9 y1 .
�
� ���
Subscribed and sworn to bef
thi s �_ day P , 19�i .
a'
No*ary Puulic, Wlnnebago County, Wisconsin
� l�y Con:mission Ezpires: /�'9°L
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