HomeMy WebLinkAbout0005329-Electric (service change) � _ CITY OF OSHKOSH N° 05329
PERMIT APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC �PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS ��� — u�� ��"'�U � PLAN NO.
OWNER � o�
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DESIGNER
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USE/NATURE OF WORK ' `
BUILDING CON7RACTOR
Size Sq. Ft. # Rooms # Stories Height
Foundation Class of Const. Occupancy Permit
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HEATING CONTRACTOR
' Heat ❑ A/C ❑ Vent ❑ Fuel/System Heat Loss BTU'S
.
ELECTRIC CONTRACTOR
Electric Serv. New Chan e Tem j
❑ g � p ❑ ype/� Volts / ''� Amps�_v
/
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
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FEES: Valuation $ �� U �– Permit Fee Paid $ �Z v Park Dedication $
ISSUED BY Date � � —� � Final/O.P. [ `�-��_
In the performance of s work I agree t e orm all work pursuant to rules governing the described construction. ►
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SIGNATURE �� �����
AGENT/OWNER DATE �
ADDRESS ��� "v �v �' �� � ���/
TELEPHONE#
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AFFIDAVIT BELATING TO SECTION 13•12 tc ) OF A GENEAAL OADINANCE
OF TE� CITY OF OS�OSH AELATING TO TF� LICENSZNG OF ELECTASCIANS
AND PHOVIDING PENALTIES
, STATE OF WISCONSIN) '
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• WINNEBAGO COUNTY ) �
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r,� /s �' �
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Name Address
first being duly sworn on oath, deposes and saqs Lhat he is not
a �iaeased el.ectrician in the City of Oshkosh and that he has
appl�ied for an electrical permft to do electrical work in a
residenae and/or ausiliary buildings (intended svlel�r for pur-
poses associated �rith a residence) �hich is owned and occupied
by him, or is being ccnstrvcted in his name, as his personal
home and that said residence or auztliary buildings being sa
arired are not to be used vr erected tar rental purposes or for
� resale to present or prospecti4e purcha.sers.
A2'£iant understands that the electrical work authorized by
the permit applied for in connection with thls at'fldavit, mvst
be done only by this affiant and that he cannot employ others to
assist �rith the electrical work but members of his immediate
faaily.
Dated this � day of , 19 ��
��� �,
Subscribed and sworn te before
this day of , 19 0/.
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Notary p�t�Yic, Wlnnebago County, 1Jisconsin
Mp Commisston Expires: �� �� ��
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