17 PLEASANT ST - BUILDING INSPECTION (3) CK �93
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CITY OF SALEM
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OIfA.Drlti P1RMff APPUCAI 11 PM
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PLi !LL Our LiiifiiliiI.Y a OOINRNmy TO AVM OM AYi N PIIOOLf1r
M THE INSPECTOR OF WAXImm.
The L.Lda mip - hemW applies for a pomt to build a000rcftlo ft.tokowhq
Owmrs Name 2J 6 rl-.lam rz-t
3i s Ad*m a Phone /--7 /*ggnj�/ .sf c9�e1 yra92
ArslrbWs Name
l Address a Phone c 1
Ilma nice Name •
Address a Pharr j 1
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APKWTION FM
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BUIMUM DEPARTMENT
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PRESENT]aAffff+o ADDRESi � � Q�oo.�ar� •S� .
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Mafia Q ICJi cad p a)lov anc11 boioWwaefa b aljyt as .�bl�N&O deea mol pOMC/• .
lksme�.paovided tbst is o"ar aet d
DEFD9rMOFHONffvWNm
Pcnoo(S)wbo wow a parcel e(W W ca w&k&behbc asides a bueadt to tesidR op�ddeb k�� .
beaded to bS a one to twvlaadCr dwcl�auachod or dwchad Rrueatra aooeootFsLatl motba ooaSidetad
farm m w m A penm Vbo construcb awe t m cm bemc k s two-year Period
a bomcowma Sue&lwm m=e chaff smbrdl to the Bund 4 OffidK f W*A banft���
Bn3l ft Oificiai,that belslte be nspom'bk to all wdt Week pabrMad
The wdamp ad-bomeowne Lm=aS>aPMLI%ft fa=nPft=wuh 1be Sun Bad Code d
otha appliabk goo by-kwS,nice cad te=aktiom
The=&mpsd-homeowne ceruf%that&rhha wders+ard.t&e CSC'of Ss �.
miaimmm bdpcW=pmacdoas an mems d mgma cad thn blshs wM wad
regalr®ert /
HOMEOWNER'S SIGNATl1RE
APPROVAL OF BlT! ING INSPECTOR
See otber side for soft code
HOMEOWNER'S EXEMPTION
The cods sums that: -my hcv=vtna>ufcnmbg for wrbkb a bnilttint pamk is qlp"sW W
exammpt 5a®tin puyWoos of Ibb secdon ($calm 29p u-Uccsint of Gmrnwdm Supervises;
provided do Is a bcnwcwaa aapta.pasco(a)to bhe to do.suca wvd6 tham rA&boeotowaa d"aA
mq ugowwmen wbo we fhb camptlem we irrware thtt dmcy Stem+s ombs dw xeyamsIMUq aft
rupavism(see Appcadh Q9 Rub sad Replsrkw for Lktoatot caastrecdoa Supervisors,seN1,N
.2.29)6 7Ms lsdm of awsrawe ofka rcrmlfis iA serious problems psrttieu1ss10 svLea the loseowae ffia
anikaned pcm ua in Fhb case yam Bond eammol promed&Saba th vniwased papa r 1t++wla erid
llama a Sopenisgr. 7be bomesw7tr owb&as suptnleor bm nttsusie�restoosSll< .
To earme dw the hototowner is tally swore of hilb•m=ponsk16*4 um my Ime mqAM.ea fiat
of the permit sppllodM that Ae bomeowner eenfr doe he/she midasand :dw ispomlbilkin eta
mpavbor. You mq tare to amcad sad adopt ones s krakurmVaNlao to Ire is your oommmi4.
mouc rpwrmw DRAnmm
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DISPOSAL M I)MN AFFIDAVIT
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MUM PfitW CLUELY)
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shown otboa ft a*man be dLpo w in a p mpab%s a wu dlw"
heft a ds&W by MM d K SIX&rod die bua ft parmib or floe AN a+e to
io&db as lomdm don haw.