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CITY OF OSHKOSH N°- 38424
n PERMIT - APPLICATION AND RE R
.
CO D
TYPE: BLDG ❑ HTG ❑ ELEC PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT `
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ADDRESS Z p-�i� PLAN NO.
OWNER��•r /r7'�v/
DESIGNER
USE/NATURE OF WORK
' 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 (LC�yI,L�L��l��I�LG�
. Electric Serv. New ❑ Change ❑ Temp ❑ Type 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 S Q �d J Permit Fee Paid $ � • �`� y Park Dedication $
ISSUED BY �"�` ` Date �f/I��/ �— Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE �!L �! G��""'� � � `�/
" AGENT/OWNER DATE
ADDRESS -�l�- � �CC� yt�� K Z 3 3 3 �-�L S'
TELEPHONE#
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�, AFFIDAVIT FIELt1TING TO SECTION 13.12 (c ) OF A GcNE.�AL OADINANC�
OF TI3E CITY OF OS�OSH AFr.aTING TO THE LICENSING OF EI.rCTAICI�iVS
� AND PHOVIDING PENALTIES
STATE OF WISCONSIN)
) SS
WINNEBAG.� COUNTY )
� � � � .,� r� �� � 3�z � . .,� _ � .
(Name Addres )
flrst being dulp sworn on oath, deposes and says that he is not
a 2lcensed elect:fc:an ln the Cit� of Oshkosh and that he has
applied for an electrical permit to do eZectrical wvr�s in a
residence and/or aua111ary buildings (Sntended solely for pur-
poses associated �rith a residence ) �rhich is owned arid occupied
by him, � or. is being canstrvcted in his name , as his persanal
home and that said residence or auxiliary buildings being so
wire� are not to be used vr erected 2'or rental purposes or for
resale to present or prospectl4e purchasers.
AfPiant understands that the electrical woris authorized bp
the per.ait applied For in connectlon •�rith this af2'idavit , mvst
be done onlq by this affiant and that he cannot employ others to
assist �ith the electrical woris but� members ef his 2mmediate
fanily.
Dated this � ( day of /yi�� C' ./� , lg�.
� c�
Subscribed and sworn to before
this ��_ d.ay of ��C� , 19 �'� .
�� �o
�Jotar� ?uollc , '�Jinne�aga Count�, �disconsin
Mr Cammission �x�ires: