0155 WASHINGTON STREET - BPA-11-2004 REPAIRS **sreEf L{-1 -:1iJD APPROVED BY T44E
u�ISPECJ. ,PAP A_P.E1�l�lI1T B,EWG GRANTED
CITY OF SALEM
No. L4 0,
2-Zrd .t Date
Is Property Located in Location of
the Historic District? Yes_No_ Building \Y�
Is Property Located in
the conservation Area? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, 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 according to the following
specifications:
Owner's Name �S QSS
Address & Phone OW) ` ,�7 - u a P
Architect's Name
Address & Phone
Mechanics Name
Address & Phone `� �s V �� Sl�
What is the purpose of building? 2AA1%C_ / i Nf A(( N,� \l t,oac� �l oa2 5 , ,.3 A((
�fl t-ti Rs
Material of building? If a dwelling, for how many families?
Will building conform to law? k Asbestos?
Estimated cost ST 0 city License# N P' State License # C S OF q S LI
Home Improvement
Lie. aE
Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE 1
r w s
w� llS , •
5q 0
c, "t
MAIL PERMIT TO:
No.", a
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT,GRANTED
APPROVED I
INSPECTOR OF4BLDINGS
C
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