11 BURNSIDE ST - BPA-2004-876 ' a
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JdSOICTL{A fA�IQA 0P.EF. RM s GRANTED
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lJl CITY OF SAtEM
Is Property located to Location of
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Is Pmpe"Looded in
eve C ismation Area? Yea_No�C
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 PROCIMIN O
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name a �� A
Address A Phone 1/ i i,t�.� L ��`' j9m
Architect's Name —
Address & Phone L )
Mechanics Name
Address & Phone �� / (�.C�/1a�7/JAfi`?/�J Z2; ,�A�JdLc/
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Lie. /tZi�Lg '-Signature of A,ppl t
SIGNED UNDER TH
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
WM
MAIL PERMIT TO:
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