7 ROSLYN - BUILDING INSPECTION fL*NS1AV6T13EgRW9#ND APPROVED BY TiIE
1M8PE 7=1,PR IDR TD A PERtIATf BEMG GRANTED
CITY OF_SALEM
Data 0
-11
Warder_
Zoning Distdct
Is Propony Located in
the Historic Dlatdat? Yea No �! Location
t� of
Is Properly Located In
Q»Corowvatlon Aran? Yea No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) R Install Siding, Construct Deck, Shed, Pool,
RepaidReplace,�Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '.
The undersigned hereby applies for a permit to build accord„ig,to the following
specifications:
Owners Name I r 1 {2S
Address & Phone I�S�N� S� sz&- (Orn Z(n S—S-b l
Architects Name
Address & Phone f
Mechanics Name
Address & Phone ¢
What b B»PWPCM of bidWW Y 6 CA� , f e.41(1P..P
Alat rw at trrldrq? n a dwoft ,for how many%mees?
wa bxaift conform to law? Aa6eetos?
Estimated cost ZS CRY License a stator Li anae e
Brea Igroveraent
Lie. i
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION
(f OF WORK TO BE DONE
MAIL PERMIT
-7
Oi9 70
No.
APPLICATION FOR
PERIAff TO
LOCATION
PERMIT GRANTED
19
AP OV f D
INSPECTOR OF SUWDINGS
W. . W sAum
BURDING DEFART M
HOMEOWNER LICENSE EM4PM0N
Place Air
AOkffAW,iF� k AA,
TELEPHM
pn>s�rrrlaAn nqa ADDRES= �(0 2 ADMMW
M,-A��GC�deq A+ 01 cl3D
The cwmm c wmptko gf"bc .+ne r�was wcndcd w bw%&ewoeropmrW weil:a oiTWO
th>fu a]eo,sa to allow toeh>soratowaers eo en`aie tm bdNidtgllor bbs wbo aoa aot paws tl
]iQaee..pvovided eb�is e.r.ei as ear wher.Ysa .
DEFR6TIONWHOAgOWHM
Pen=(s)w•bo owm a pact]of bud oa wbkb bchbc mida cr brut to resid0.m wbidt tlws k,w k
inrerded to be,a one a two bny dwclgo&avadrd at dwdrd svucava WMMM7 b ntcb m a APW
farm svucwm A peram wbo eora ro m more tlmi oat home in a two•ycar period sbA aot bt ooasid and
a bomwwaa. So*`h moow mf sbalvAmit to the Bwldvg Od+cbL m a liwp Ncoqd*lo*a
Bwl ft OMci4d o bdit bt nqm mbk to all rob work pafamed tads the bpaML
The wWadp d'bomwwme ae=m resparmbiliq for c=pft=wide the State Boittmg Code ud
oxha appNcabk foes by-kws,rala and n%ubdma
Tbc u dersipad-homwwna-ecrd5a that Waht wdastands tbt Ciq of Salem 13WWh g Dgwama.
nib imus brp cdm pmcsdwo and Tcq*+mm and tint hldn well=a*wM aid pacdmet d
HOIMOWMIS SIGNATURE
APPROVAL OF BLMMING WSPECTOR e&�
See otba sdt for test code
k
Ho EOWNER'3 EXEMPTION
The cods suta tAst 'wiy bonnownerlerforming-iv*for which a bolhliog pettnh is req"sbal k
cxempt Sam taw pmvidam of"acdon(Sectiw 7 PIA-3jccoslog of Caattrnett" SgervEao O
provided that is a 3omeowna enpta p pmm(f)ter bra to do.such work 6 t sud Loaoeowae:dtait ool
s superviaat;'
boupavownw
wfw use this exttt pku we inmwm that they ate muming the psyooahths Ica
sopavtra(see Appendix Q.Roks and Regulmloa far 1Jocosing Cooatnwdm Erpesvbars.faeta
.7.35. wbm the horaeomter*"
unileeared peaomt In tb can yom Bard armor promo l aSabw eta mt9oeaaed pc*m as llw0 w!S
liecaacd Snpovisor. Tie booseoevxr acting as supadaw Y ogtmase restoosRlp,
To ensure that ta homeownes la Sdb swan of bilber tesponsibliltles,rsmp oomra�Qdea tagdw:as Lett
of the pcnal appliadM that the kmwwua ccrdt tlm Waive wA= mrds tin respanslbMw aft
supaybm Ym may can to wacud and adopt wbli a trmlocnifioties!sc usa la yom comas mm*
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