75 DERBY ST - BUILDING INSPECTION JACKET -PL-A"SlMT-9Ef bE9.1AN9 AfWROVED By T44E
JMSPF.CI'DF.1 PWR TD.A PEBW B,FJNG GRANTED
/ CITY OF_SALEM
No.! D �� '�`� Date
Is Property located in Location of
the Hstoft District? Yee No !/ Building
Is Property Located in
d»Conservation Ares? Yes_No 1/
BUILDING.PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: .e�rfov�iror�s
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 /3exe'oe v Cm-O'op
Address & Phone �73 2ecj6v 5T. 5"e /lei ( 1
Architect's Name il/'vide
Address & Phone ( 1
Mechanics Name X ' ,4
SG A e-o-T,7er
Address & Phone Alee-Alj M mil.¢ o z�2,� (W ) 992 -od5 0
What Is the purpose of Wldirrg? 1964'c a 4'iL e F
mmalal of brrltdirrp? % ri/c II a dwWN,for how many famllles?
WW bulldiny contorm to law? S Asbestos?
Edmated cost 2 &00 Gty license M IV A State lk== M Oh(— 9(i- -
Sam improvement
Liz. a
Signatu f Applicant
SIGN UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
Ale w (e f 4f, jg:Ze4Trt 1 tu/
.S�eeTROcle-
MAIL PERMIT M: Slr �e�.ca� if�Saitr B Nteo/�i�.,� /YID oz N 95�
r
No.
APPLICATION FOR
PERMIT TO L
7
LOCATION
~ PERMIT GRANTED
n l 2Chf.-).5
4 APR OVFD
FISECTOR OF ILDINGS
' � N
t
• � Q
O
N