35 STATION RD - BUILDING INSPECTION ate
ItIM WAVE#NA kW o APPROVED BY TW
MWECM PRW W A.PEAW BEING GRANTED
C CITY OF_SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Rwoof. 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 acconkig.to the following
speciticatlons:
Owners Name
Address 3 Phan S �� v,� ��✓ ( 1 2 L S�
Architect's Name
Address d Phone
Mechanics Name
Address A Phone 3 D
wlrr is VW purpm if WN*W s-
mom of tall w - �/o &-�K N a dwa0 for how mmy Mmilm? /
w0 Eulft eaft" to law? Aobaao•? �i U
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SMM THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT M. t c-J� nx/n-e.—
APPLICATION FOR
PERMT TO
LOCATION
PERMIT GRANTED
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INSPECTOR OF BUILDINGS
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Workers' Comperwtia Insurance AffWwk
.. wttba w'lAdpsl place of beairws an
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do bereby'cerdy under slat paint and peslildas of pw*yo slop
A 1aan emplv)w pnwMing workers' compensation qr es co"Pile for n siuyleriet wwkbg on
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Insurance Cem tow room Number
1 am a sole proprksor and haw so ono working fir me In any cap6acky.
0 1 am a sok proprietor, general Commuer or homeowner (circle one) mad how bled slat
contractors listed below who•haw the following workers' caimlpen:mtlee po0dep '
Contractor Insuranie Company/polhW.Number
Comraesor Insurance Company/Po Numbw
Cotwacar Insurance Company/Policy Numbw
0 1 am a homeowner performing all the work myself.
•1 rnelnHy ens a eaar of arY A"MM We be br.Wftd om On Ocoee A bwdtwew et Or M ter ca.era p vwlka/w wA om Ubm w omen
cowrery Al f.owa~Saw+SSA of WU 15 2 can lead w aw:reecho of abWom aeaade carwint N a aq of as wet I.NO aWor sae
omen'ierwr.nm a ys a do#evuWa in ncc ben et a STOP WORK ORDER am a Ina N s looAo a an W w oa.
Signed this • C9 �2 Ne;K day of
.icenicciicrmitte oulldin( Geparsraent
�Jctnsinf Eaart
Seiectmens Office
�eJlth Gegr:mer,�
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