3A FILLMORE - BUILDING PERMIT APP _ 1
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DATE:
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Citp Dfar�m, a�5atfjuSEtt
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRAKTED
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Building Permit Application For: Location of Building
'(Circle whichever applies) Roof, Reroof, Install sidin t Deck, Shed, Pool
Addition teration, Repair/Repla Foundation Only, Wrecking
Other.
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of BuOdings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name:ioiClerrrow AgiaeL_'owkQD contractor:4)111119rr, U 5e64nras
Street S91c n city /J7 ►9 street A170 y d.J city rl* �kv
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State Phone ( ) State Phone
Architect: City of Salem Lick!
Street 3/Q. f 111^,pac city 401v^ State Uc#0?yyV HIP#
State Phone e?;Ir) 325--,73 / Homeowners Exempt Form_—yes no
Structure: (please circle) Single Family, Multi Family# Other
Estimated Cost of job S
Will building confirm tq�(aw?_yes no
AsbestosY_yes uo
Description of work to be done: _1
g2o / L q l�v a�f� (it nl19tn
12c.9.t a 11 r em
Drawings Submitted: yes no Mail Permit to:g w
/.. (7-Sd? S
0 it 19
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Si tune of Application SIGNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO B&r.OMPLETED WITHIN SIX(O MONTHS OF PERMIT ISSUED DATE
Department use only: Perfla# _-4ning MaplLot
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Permit fee$
COlIMMS:
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