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� CITY OF OSHKOSH
N° 45161
PERMIT - APPLICATION AND RECORD
TYPE: BLDG ❑ HTG ❑ ELEC�PLBG ❑ SIGN ❑ ZONING FLOOD PLAIN HEIGHT
ADDRESS � 9�� �• �a � PLAN NO.
OWNER ����`''
DESIGNER
USE/NATURE OF WORK �� %���
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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
r�
ELECTRIC CONTRACTOR
Electric Serv. New �Change ❑ Temp ❑ Ty � Volts�l� Amps D v .
Fixtures Switches Receptacles Circuits
P�UMBING 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 $ D 0 O . O � Perm�t Fee Paid $ S �� � Park Dedication $
ISSUED BY Date 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
TEIEPHONE M