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DATE:--�_
Citp of &alEm, 1Ra55arbu5Ett5
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
Building Permit Application For:
JC rcle whichever applies) Roof, eroof, nstall Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other: t
PLEASE FILL OUT LEGDiLY & 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: //ff
Owners Nam (2'15t Contractor:
Street Citv= Street Q/✓6 City «�
State, Phone 01) - State ly Phone(97e)2!V-.-2-?75'
Architect: City of Salem Lich
Street City State Lic# '�� HIP#
State Phone ( ) Homeowners Exempt Formes no
Structure: (please circle) Single Family, Multi Family# Other
Estimated Cost of job S
WiU building confirm to law? ✓ Yes no
Asbestos?_yes/no S
Description of work to be done:
Drawin u ttte ✓ no Mail Permit to:
X
Si to of A plic n, C D UNDER THE PENALTY OF PERJURY
CON of
TO BE% OMPLETED WITHIN SIX(6) MONTHS OF PERMIT ISSUED DATE
I
Department use only: Permjl'# Zoning Map/Lot
Permit fee $
COMMMS: