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AFFIDAVIT FiELATING TO SECTION 13.12 {c ) - OP A GENEAA.L ORDINANCE
OF THE CITY OF OSHISOSH F3ELATING TO THE LICENSING OF ELECTF?ICIANS
AND PROVIDING PENALTIES
STATE OF WZSCONSIN)
) SS
WINNEBAGO COUNTY ) '
. �
�'� a.� � � � v � , aa � � �� ��'�.�
me Address
f2ret being duly sworn on oath, deposes and says that he is not
a liaen8ed electrician in the City of Oshkosh and that he has
applied for an electrical permit to do electrical work in a
residenae and/or auxiliary buildings (intended solely for pur-
poses associated with a residence ) which is owned and occupied
by him, or is being constructed in his name , as his personal
home and that said residence or auxiliary� buildings being so
wired are not to be used or erected Por rental purposes or for
resale to present or proepective purchasers.
Affiant understands that the electrical work authorized by
.the permit applied for in connection with this affidavit , must
be done only by this affiant and that he cannat employ others to
assist with the electrical work but members of h1s SIDmediate
faaily.
Dated thi s day of �ti�' e , 19�.
.
. �
�
Subscribed and sworn to before � `
�
thl s`� � daY of � 19�'�'�-
�
Notary Public, Wi nebago Cou�ty, Wisconsin
My Commission Expirss: ��OMlrU�,SION IXPIRES�� 1�3
. ,. . ,_ ..__..,:_
PERMIT NO. l/O6 � . APPL. DATE � �-< � ��
ELEC. CONTR.
OWNER
ADDRESS � C! l � '/ �
NATURE OF WORK ''
ELEC. SERV. NE4�1� CHANGE TEMP.
DESC. TYPE VOLTS AMPS
FIX' S SW� S RECEPT' S CIRC' S �
APPLIANCES
SIGNS
INSP. ROUGHIN SERVICE FINAL /' ?�
EST. COST � � PERMIT FEE �� �' DATE PD.
REMARKS
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