HomeMy WebLinkAbout0027600-Electric (remodel) � CITY OF OSHKOSH N° 27600
`' PERMIT - APPLICATION AND RECORD
TYPE: BIDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS � �� `� � P NO. �
OWNER ' �
DESIGNER
USE/NATURE OF WORK �/�-�/`�2O yL/�-�i'tsz�� -_—
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 f
Electric Serv. New ❑ Change ❑ Temp ❑ ype Volts Amps
Fixtures� Switches `�---Receptacles '��-�cuits � !
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
f/dl' ac o�
FEES: Valuation $ ' Permit Fee Paid $ ��—'� Park Dedication $
ISSUED BY Date e� "!�� �� !� Final/O.P.
In the performance of this work I agree to perfor all work pursuant to rules governing the described construction. '
SIGNATURE �
/ � � '
� AGENT/O ER ATE
ADDRESS D � �� � `��! �� �� ��//
TELEPHONE#
AFFIDAVIT BELATING T0 SECTION 13.12 (c ) aP A GENEAAL 08DINANCE
OF T� CITY OF OS�OSH �ELATING TO THE LICENSING OF ELECTSICIANS
� AND PAOVIDING PENALTIES
� 3TATE OF WISCONSIN)
) SS
WINNEBAGO COUNTY )
� � � d�
� ,
Name Addre s �..����
first being duly sworn on oath, deposes and says that he is not
a 2laensed electric�an in the City of Oshkosh and that he has
appl�ied tor an electrical permit to do electrical work in a
. residenae and/or auzillary buildings (intended solely for pur-
poses associated o�ith a residence) �rhich is owned and occupied
by him, or is being ccnstructed in his name, as his persanal
` home and that said residence or au=Sliary buildings being so
xired are not to be used or erected for rental purposes or for
� resale to present or proepecti4e purchasers.
Atfiant understands that the electrical work authorized by
the permit applied for 3n connection w2th thls afPidavit, must
be done only by this afP2arit and that he cannot employ others to
assist �rith the electrical work but members ot' his immediate
fatnily.
Dated this day of � , 19��✓
� `
Subscribed and sworn to before �
�
�h3s �,w �Y oF �i:t� t , 19�.
� j� i ;
� �!�' �`� e)cr{t
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Notar � Pub11c, Wlnnebago County, tidisconsin
Mq Coma3ssion Ezpires: � ��4 �� J �1_
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