1 MOFFATT RD - BUILDING INSPECTION (2) PL-01 ~qSE fKA9400 APPROVED BY T44E
J UPJ:C =PWR TO A PMW BEING GRANTED
CITY OF SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Retool, Install Siding, Construct Deck, ,
/ Shed Pool,
Repair/Replace. Other. P l& S4v2 / „�p/�te 1, Pool
PLEASE FILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accor&g.to the following
spec ioations:
Owners Name KK4d/(- -Q'Vim/
Address A Phone 1710 FT-4f-1 l /Zl) 3'16-k'
Architect's Name
Address A Phone ( 1
Mechanics Name
Address dr Phone
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re of Appiicant
SNOM UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORKTOBE DONE
MAIL PERMIT TO:
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