4 VICTORY RD - BUILDING INSPECTION f URM111 tlST11E fNAjkW D APPROVED$Y TN E
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CITY OF_SALEM
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Permit to: —
BWLDINO PERMIT APPLICATION FOR:
(Cirde whichever apply) Root, Retool, Instal Siding, CmXuW Dock, Shed, Pool
Repak/Repiace. Other. S h e c IZ m r r,
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS:The undersigned '
hereby applies for a permit to build aocorcLig.to the following
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Owner's Name o u`r to-2(,(,,, N
Address a Phone W l r-OiZy fflei 7q 5 g3z.S
Architect's Name
Address a Phone t
Mechanics Name tt✓1 i41Z Rl (�
Address 6 Phone 7 Lri-✓RTIER 2d Sfo Z1037
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mom of fatldttp? taro�p � 1t a dwNWq,for how mitpy hit"?
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F.aittwse a,a / 5�00 city uoaw• 2010 sew f bow r CS o 7(o Zqb
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SgnaWn of Applicant
SKIIM UNDER THE PENALTY,
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
R&SE .120—lb N
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MAIL PERMIT T0: 7.a LRJRi t6Z
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APPLICATION FOR g #.
PER111r TO
LOCATION
PERMIT GRANTED
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CTOR OF 13LJILDINGS
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