284 WASHINGTON ST - BUILDING INSPECTION (5) fL"GIAtteT*EfiLiB*ND AI PROVED BY Tm
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111OR TD A PERMIT BEING GRANTED
CITY OF SALEM
No. DEN >�3
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BUILDING PERT
Permit to; PERMIT APPLICATION FOR:
(Circle whichever apply) Root, /Rpemof, Instal Siding, Construct Deck, Shed, Poo/l,
Repair/Replace, Othw._j,;
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accortLag•to the following
speoNimbons:
Owner's Name 116-11S L- GeWn/
Address & Phone (w) 91'G--S YF 6 /C
Architect's Name
Address d Phone / ( )
Mechanics Name L(>17 / Vn ice/ PL� z �o
Address 6 Phone �S �19DC�/�/Se7�-� (774&�-03/�J
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Signmure of Applicant
SNUM UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK-TyyO��BE DONE
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MAIL PERMIT TO:
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contractors; listed below who•bave the following workers' compensation poBdest
Coeaaeu w insurance Comparny/Polity umber
Contractor Insurance Company/Poky Number
Contraeor insurance Cornpanry/Pocky Number
() 1 am a homeowner performing all the work myself.
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