11 STATION RD - BUILDING INSPECTION (3) 30 ov '
fLkNS1ftIST-9EfIWB4A9 APPROV[{) BY 774E
JMSPZ=DR PRDR TD A PERMTf BFJNG GRANTED
CITY OF_SALEM
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Is Property L00ftd in Location of 11
ar Hhbdc DW t? Yss No
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Is Promiy Locabd In
Ur coneana*m Ann? Yn No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, 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 accor(L-19.to the following
specifications:
Owner's Name ,cam �2LKle
Address & Phone / ".p4 /JaG ( 1
Architect's Name
Address & Phone
Mechanics Name
Address & Phone
Wirt Is 90 PaPM of bWldkW 5•'le� Q
mdWW of buMdkq? (tic n a dwMWq,for how many taman?
Wa brrldrq conroml to bw? Ye S A"Oos?
Edna cost Id 6 My Lkmm r sba Lim=w
Sii7rtature of Applicant
SIGNED UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�Q9de"
MAIL PERMIT TO: � o n o ✓�P/
No. - o�
APPLICATION FOR
nn PERMW TO
/t 2lI4.�t TD fah
T
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LOCATION
PERMIT GRANTED
19
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A
SPECT OF BUILDINGS