HomeMy WebLinkAbout0031514-Electric (service change) _ ` s
, ;
CITY OF OSHKOSH N° 31514
`' PERMIT — APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC (`�� PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT `�
- - - - - - - - - - - - - - - - - - - - - L°- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
r
ADDRESS � 3 � � �/��� PLAN NO.
OWNER �� '
DESIGNER
USE/NATURE OF WORK��l�C.-
BUILDING CONT�RACTOR
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 ❑ TypeU VoltsZ�n Amps ��
Fixtures Switches Receptacles Circuits `�
�.,c�.i • ��-f-- ��f C� �
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
�
i
FEES: Valuation $ 3 e � • `J d Perm�t Fee Paid $ �� '�� Park Dedication $
ISSUED BY Date Jl,��rt Z Final/O.P.
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
SIGNATURE
AGENT/OWNER DATE
�
ADDRESS
TELEPHONE# !
z
r �
�
AFFIDAVIT BEI�ATING TO SECTION 13.12 (c ) OP A GENEAAL 08DINANCE s
OF T� CITY OF OS�OSH F�ELATING TO T� LICENSING OF ELECTAICIANS
AND P80VIDING PENALTIES
t
3TATE OF WISCONSIN)
) SS
WINNEHAGO COUNTY )
�o � !� �- 6, �L , Z 3 s � t/�,��� �/�
Name Address
}
2'irst being duly sworn on oath, deposes and says that he is not
a 2laensed electric�an in the City oP Oshkosh and that he has
appl•Sed for an electrical permit to do electrical work in a
residence and/or auziliary buildings (intended solely for pur—
poses associaLad a�ith a resideace) �hich is owned and occupied
by him, or is being constrvcted in his name, as his perscna,l
home and that said residence or auziliary buildings being sa
vrired are not to be used or erected for rental purposes or for
� resale to present or proapecti�e purchasers.
AP�lant understands that the electrical worls authorized by
the permit applied for 2n connection �rith thls aPfidavit , must
be done only by this atfiant and that he cannot employ others to
assist �rith the electrical woris but members o£ his immediate
Fatai ly.
Dated this � �� day of �� �..2 , 1gL?�
—
Subscribed and sworn to be2'ore
�hls �,�' ; day cP , 19��--•
�
��
Nc'r,�r, P�iY�11c, Winnebago County, tJisconsin
, �
l�g� Ccmmission �zpires: �� � /
. i