HomeMy WebLinkAbout0005010-Electric (a/c) /� CITY OF OSHKOSH N° 05010
`' PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS � �L � -�:�j� l!� �^�� PLAN NO.
OWNER L�1
DESIGNER
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USE/NATURE OF WORK LL���� � rir�-c�
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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
r
ELECTRIC CONTRACTOR
Electric Serv: New ❑ Change ❑ Te ❑ Type Volts Amps
Fixtures Switches eceptacles 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
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FEES: Valuation $ `'^ Permit Fee Paid $ � Park Dedication $
ISSUED BY Date �^ �O ,� Final/O.P. �"I � - �S� '
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE � �^�I `- / �� / ., :
AGEN /OWNER DATE �
ADDRESS r �c0 � 2� �p / � ,
TELEPHONE#
AFFIDAVIT &EI.ATING TO SECTION 13.12 (c ) OF A GENEAAL 08DINANCE
OF T� CITY OF OS�OSH F�ELATING TO T� LICENSZNG OF ELECTAICZANS
AND PHOVIDING PENALTIES
STATE OF WISCONSIN) '
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; WINNEBAGO COUNTY ) �
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�� � - �o �� 1 �..�1� s�o � �1v � ����
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Name Address
first being duly sworn on oath, deposes and says that he is not
a 2lcaensed electrlcian in the City of Oshkosh and that he has
appl�led for an electrical permit to do electrical wvrk in a
residence and/or au=iliary buildings (intended svlely for pur-
poses assoaiated v�ith a re9ldence) which is owned and occupied
by him, or is being coastructed in his name, as his persona.l
home and that said residence or auxSllsry buildings being sa
�ired are not to be used or erected for rental purposes or for
resale to present or prospective purcha.sers.
Affiant understands that the electrical work authorized by
the permit applied for in connection w2th this afSidavit, mus�
be done onlq by this afPlant and that he cannot employ others to
assist �rith the electrical xork but members cf h3s immediate
faoily.
Dated thi s ��� day of 1 �j �
, 9�
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Subscribed and swo to bef re
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t i s , daY � , 19�.
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No�tas3� Pvbl�c, Winnebago unty; Wisconsin
My Commission Expires: �f`��`" ���
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