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CITY OF_SALEM
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Is RoWly Loceled In
: IN Caanvalon Anta9 Yam No
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof. Install Siding, Construct Deck, Shed, Pool,
RepaidReplace. Other BAW*rvom 6) l(j
PLEASE FILL OUR L E4;IM3LY 44 COMPLETELY TO AVOID DELAYS W PROCESBM
TO THE INSPECTOR OF BUILDINGS: '•
The unclemipned hereby applies for a permit to build aocordwig•to the following
specifications: ee n
Owner's Name /V c / ��n cJ A� U a G EC
Address a Phone Wa
Architect's Name
Address Q Phone ( ,
Mechanics Name
Address A Phone ( 1
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$IUD UNDER THE PENALTY-
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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NON
APPLICATION FOR
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LOCATION
PERMIT GRANTED
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BURDING DEPARTMENT
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