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DATE: 6'�7`do c,F
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERNUT BEING GRANTED
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Building Permit Location of Building Application For: /�K3�i
'(Circle whichever applies) Roof, Reroof, install Siding, Construct , S Pool
Additio�Repa fiteplacr,Foundation Only, Wrecking
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:
Owned Name, Contractor.
Street •✓a s1�, a 1��„ .._,f� City <,/�n, Street oz IF/ r Ali City L�
State�l(f Phone 078j 7`/Y - 5-eV,? State Phan
Architect' City of Salem Lic#
Street City State Liao 0-T LBxP#
State Phone ( ) Homeowner Esempt Form�rs-o
Structure: (please sisele) e8�aaiitily, Multi Family q 0�
Estimated Cost of job'S
Will building swofirm to law! /yu no
Asbestos?--yes
Description of work to be done:
Drawings Submitted es no Mail Permit to:
x
Signature of Appbcadon.S.GNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO B } OMPLETED WITHIN SIX MONTIIS OF PERMIT ISSUED DATE
Department use only: Permit# Zoning MapJLat
Permit fee S
COlR1MS:
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