10 RAND RD - BUILDING INSPECTION ±n'
Alsikads aft. *OVER 1R NTE
IUD . .P .sEINI"s GRANTED
.lye.
CITY OF SALEM
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Pmp
LOGMd
Lmation
theHatwicy DI inYek_ No Da ]ling of
ft C n8*rW1 o ABM? Ya_No
BUILDING PERMIT APPLICATION FOR: '
Permit to:
(Circle whichever apply) Roof, Remof, Install Siding, Construct .Deck, hed Pool,
Repair/Replace, Other•.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCNNNNG
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name n clw� n 01H S
Address & Phone J 123\/
Architect's Name
Address & Phone j 1
Mechanics Name
Address & Phone
Whet Is tlN gapoa q bWWYp? 571vxac� e_. 1SAed
m"W of taulow �'3(706 1 a rim a ,for how many fame"?
WE bulldog=iomt to Lew? Aabeetw?
Eelmafed coat. 2 CID0 .Od My Uce r N A state e
Rom Lpro....nt V
mac. aA!
7
lgnature of Appll . t
SIGNED UNDER THE P `
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
'Iq
i
"{ MAIL PERMIT TO i
' y
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT
_IGRANTED
AP vFo
INSPECTOR OF BUILDINGS
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