HomeMy WebLinkAbout0010521-Electric (enclose existing front covered porch) /� CITY OF OSHKOSH No 10521
`' PERMIT — APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS � ^� ' � �` 5 PLAN NO.
OWNER �
DESIGNER
USE/NATURE OF WORK "v ` ��� �"��`� ,
,
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 ❑ e Volts Amps
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 $,` °z- `! Park Dedication $
ISSUED BY Date �d f�� Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
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SIGNATURE ���� P���� "r'I �-�/e�I
� AGENT/OWNER DATE �
ADDRESS__3� � �+ • (� t`� �S/.(.�vSi� �ic�) 13 3-6�77
` TELEPHONE M
AFFIDAVIT $ELATING TO SECTION 13•12 (c ) OP A GENEAAL OBDINANCE
OF THE CITY OF OSffi{OSH AELATING TO T� LICENSING OF ELECTBICIANS
AND P80VIDING PENALTIES
3TATE OF WI3CONSIN)
� ) SS
WINNEBAGO COUNTY )
.
� l�v� �'� i ZF/L-- � 3�7 w. iSt� �dvE
Name Address `
flrst being duly sxorn on oath, deposes and saqs that he !s nvt
a 2lcenaed electrician in the City of Oshkosh and that he has
appl�ied Por a.n electrical permit to do electrical work in a
residenae and/or ausiliary buildings (intend.ed solely for pur-
poses asaociated arith a residence) which is owned and occupied
by h1m, or is being cons�rvcted in his name, as his personal
horae and that said residence or auzlliary buildings being so
v►ired are not to be used or erected for rental purposes or for
� resale to preseat or prospective purchasers.
Affiant understands that the electrical work authorized by
the permit applied for in connection w3th thls affidavit, must
be done only by thts aPPiarit and that he cannot employ others to
assist �rith the electrical work but members of his immediate
family.
Dated this ,��"�`—` day of __��.,,��.� , 19�. :
��,w-�_-_
� '
Subs�rib�d and swvrA to b�fore
t�i s �`�- day of e , 19�
___-�
=-�-'��='�= � l��n����'_
Notary Public, WSnnebago Countp, Wisconsin
My Commission Eapires: ���'� �lo
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