HomeMy WebLinkAbout0017107-Electric �
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� CITY OF OSHKOSH N°_ 17107
`' PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELE�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
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ADDRESS���� �/�,�`�c-�.(' �U' PLAN NO.
OWNER //� �,�_ /�G� Yt� cy �1
DESIGNER
USE/NATURE OF WORK � ��� c��'�" V r o k'(
Q� ��k1 �"vt9�i1
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�� h-ti° �
Electric Serv. New ❑ Change ❑ Temp ❑ Type Volts Amps�1Z
Fixtures� Switches � Receptacles� Circuits�
PLUMBING CONTRACTOR �►�1'�-��
—BT WH Disp —WSoft —CBasin
—Lav Sh —DW —DF —San. Sewer
—WC FDr SP —Ur —Storm Sewer
Sink —LTub —Eject SS Water
Other
F�ES: Valuation $ Per ' ee Paid $ � Park Dedication $
ISSUED BY Date � Final/O.P.l�.��f�6
In the performance of this work I agree to erform all work pursuant to rules governing the described construction.
SIGNATURE ��� �� "` °� ' /������
ENT/OWNER DATE �
ADDRESS � 7 E°°�� N�✓''�E��9���ot�i �1� � j�`'/ E✓�?j
� TELEPHONE#
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AFFIDAVIT AELATING TO SECTION 13.12 (c ) OF A GENEAAL ORDINANCE
OF THE CITY OF OSHKOSH FiELATING TO THE LICENSING OF ELECTF3ICIANS
AND PROVIDING PENALTIES
STATE OF WISCONSZN) .
) SS
WINNEBAGO COUNTY )
'� < s � � , 2-��- �����-rl � �
Name Address
first being duly sworn on oath, deposes and says that he is not
a licensed electrician in the City of Oshkosh and that he has
appl�ied for an electrical permit tv do electrical work in a
residence and/or auxiliary buildings (intended solely for pur-
poses associated with a residence) which is owned and occupied
by him, or is being constrvcted in his name , as his personal :
home and that said residence or auxiliary buildings being so
wired are not to be used or erected for rental purposes or for
� resale to present or prospective purchasers.
Af'fiant understands that the electrical work authorized by
the permit applied for in connection with this affidavit , mvst
be done only by this affiant and that he cannot employ others to
assist with the electrical work but members of h1s immediate
faoily.
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Dated this � day of � a � c��.v- � , 19 ��
�.
� �J'�/ ,A
Subscribed and sworn to before
this ''; day oP �- . �� , 19�.
i����, � `� � ,�
z
Notary P•sblic, Winnebago County, Wisconsin
My Commission Expires: 7 / U�
� �� � ``� r.
PERMIT NO. ` /` � • AP L. DATE `
ELEC. CONTR. �
OWNER ��yl �/������
ADDRESS � ��5 y � i
NATt7RE OF WORK
,��YY
ELEC. SERV. NETn CHAN TEMP.
DESC. TY E VOLTS AI"IPS
FIX' S SW' S �- RECEPT' S ��C_ CIRC' S OC�
APPLIANCES
SIGNS
INSP ROUGHIN�/ - '�- ��C SERVIC� FINAL!�t� -
EST. COST 3C�0'�� PERMIT FEE /�� DATE PDJ��9-9�
REMARKS