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AFFIDAVIT AELATING TO SECTION 13.12 (c) OF A GENERAL ORDINANCE � i
OF THE CITY OF OSHKOSH RELATING TO THE LICENSING OF ELECTRICIANS
AND PROVIDING PENALTIES :
3TATE OF WISCONSIN)
WINNEBAGO COUNTy � SS
.
�/�/�S//�.�' O�� ��' , � /��ic/�/ �
Name � Addreas
firet being duly sworn on oath, deposes and says that he is not
a �iaensed electrician in the City of Oshkosh and that he has
8pplied for ar� electrical permit to do electrical work in s
residenae and/or auxiliary buildings (intended solely for pur-
poses associated with a residence) which is owr�ed and occupied
by him, or is being constructed in hia name, as his personal
home and that said residence or auxiliary buildings being so
wired are not �o be used or erected for rental purposes or for
� resale to present or prospective purchasers.
Affient understands that the electrical work authorized by
the permit applied for in connection with this affidavit, must
be done only by thts affiant and that he cannot employ others to
assist with the electrical work but members of his immediate
family.
Dated this day of /�fJ/�s/ , 19��
_ �
-�- �
Subscribed and sworn to before
thi s � day of �J� �U
�----•7�-_._r 19 • ,
,
Notary Public, Winnebago County, Wisconain
� My Commi s s i on Ex i re s; ��'y Comtriission Exp;res
p -�::ti 7,�98Z
PERMIT N0. L,�� � APPL. DATE ��j`—/�--,�,�
�
ELEC. CONTR.
0 W N E R ���r-t�c� ��=t �:-���.._2 �
ADDRESS /�j �2�,��- �
�� :=--z L
NATURE OF WORK � �
�
EC. SERV. NEW N E EM
S . r VOLTS , � AMPS
FIX S SW S RECEP S IR S
APPLIANCES � � �
d�
SIGNS
INSP. ROUGHIN SERVICE .��-zg- �� FINAL -��-
EST. COST �— PERMIT FEE � pD,
REMARKS __ - �- �� ��
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