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CITY OF SALEM
BUIIDING DEPARTNENT
HOMEOWNER LICENSE EMOMON
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HOMEOWll a
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PRESENT MAILING ADMM `/Z /1a
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DEF29TION OF HOMEOWNM w t lft on va am k,ark
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HOlaoWNER'S SIGNATURE
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APPROVAL OF B=ING INSPECTOR
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HOMEOWNER'S EXEMP'TIO
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cxer"ftm the p wWmts of this scrdon (Section 70pla r l3ctosing of Covarac"Sopavisoro;
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Urilornud pets m In this ease yow Board rarsnot proceed aYaitr:t the mweemeo pertoa at ilwarld wl�
licensed Strpa+* 71e bomeonwcr saint as supervbor b uitimat*itrapwplL .
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of the pcnndt sppiirmdm that the bomwwner ctni y thta bc/she mrdosands the TnpmwbnMa eta
supuvism. You may can to amend and adopt mxh a lorm/ctinM=tian Ow in is yottr comma