40-42 ROSLYN ST - BUILDING INSPECTION (2) i
"PU01106lAtIST9E fNA84ND APPROVED BY 744E
ASPFL` C8 PRJ0R TI)A PEI9W BMG GRANTED
CITY OF SALEM
No. -a� — Data Z e
;. Ward
. . Zm*q District
Is Property Located In Location of
the Histodc District? Yes No_ Bolidina 1 D -�c 2 IZO ter tir
Is Property- - ' in S T
the Caneenanon Area? Yee_No_
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool,
R tdR , Other: _w i *un o 1, -,,
PLEASE FILL OUT LEGIBLY 6 COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a Permit to build accord4ig.to the following
specifications:
Owner's Name t Cr; R I G t- -r
Addra s & Phone td 0-Cd Z IZ os L y N %i (6r"71 S-O 4.- gr%-o
Architect's Name
Address & Phone ( I
Mechanics Name s ' 44tmAy Honnc 0-1-
Address & Phone
wr,-a — , el t 0 (Po
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eow Improvement
Lie. I I2�!
Signature of Applicant
SKINED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO:
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i
4 NO�%
APPLICATION FOR
PEFUN/T TO
40
LOCATION
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PERMIT/GRANTED
19
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INSPECT BUILDINGS
t; 1.omriioiuncla�Jt-o�1/lalsachwsJ�O
600 W.&O .Sfred
tens.+ &Jw. Mas. Iaeelb021'/
Worken' Competwtia Inm an=AtRdavk
• • wb11.a primal place of bmbm an
se llerebr'eertiry andat 'a p.b1r and pesahisa of pr}ry, do
i) Is anemploy/sr pnwMb/mg worksna eom ossedi n covapile for MW evaployou weekbg an
�/!7�/2lCAN /�0/7�E✓tSSGs�.4,(/CE' �r�[�v�29�'lg9�� ,
lanaranp Cemoalor P "umbor
1 am a solo propriesor and haw no one wo*bo for an Is any bpodWe
O 1 am a solo proprierx, senoral comra or laoinlowrar(drds ees)and how bind tbs
commoon Ibsed below who-have tho followbM workena Ciemponsadme pa"
Comneter 1nu11ratKa Cosapatry/r
Comraosir Inmrsym Company/Pe Compavvy/Pelley Noodw
Cemraaer _ Insurance Company/roftogumboir
0 1 am a homeowner performing all the work myself.
•t reeernwe am a sw►of 06 rases..a be ke+.- sed er ON Olin A aeae of er M ler torerap:wlirMw ass M(M a aware .
ae.enry a neewM wen Seem 21A of NCd 152 an kid ar b:naeaiae d eI i wade cerueder aft a FAN S(w ens 1.NO s Wer ess
run'wsr..weer a as a era aurae in Orr term of a STOP WORK ORDER see a bw N 1100.00 a a*as"sr.
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