6&8 FLYING CLOUD - BUILDING INSPECTION i
,
fil M1AbVT19E fiA3B#ND APPROVED BY -pa
WPFCMR PWR TO A.Pl<RW JWNQ GRANTED
N��� �� CITY OF SALEM
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Is Property locaad in 1"atioa 0>
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b PMP"Ucftd In
the CanNrva*m Alva? Yam No_
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Siding, Construct Deck, hsd, Pool,
Repair ,_Other
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESom
TO THE INSPECTOR OF BUILDINGS: '•
The undersilirisd hereby applies for a permit to build accor&ig.to the folkmlirtg
speclketbns. _
Owners Name A-"� to t `1' 627
Address 6 Phone�-4 i P(�JS 78-) `7 `f
Architect's Name
Address d Phone ( 1
Mechanics Name
Address d Phone t06 ,)e� c)
What W to pupoaa at WNWW Cn� J
Ma m or Now N a dw.NMq,for raw many I m n? �51—
Wa OWkkq to law? Yi'f;, Asbe"?
F.nrn.r.d cc �oy y- c)J CIV Uc r 5 -�i.• D:,ZL(75 7
Bior I�ro....se � j�.
Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE f n
MAIL PERMIT TO: Cl 3�
APPLICATION FOR
PERMff TO
LOCATION
PERMIT GRANTED
APPROVED
1 OR of BUILDINGS
ruEuc r"OrIXTY LWAR MOR
120 MINMINWM a MWF as0'LOOM
i fALatl.IIA OI a><io
TIL(970)7484aias Ur.360
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DUPOSAL OF DMX APPIDAVA'
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. . wk#l.a prrladpel pklo of btuiseis as !/VlJ'�-
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do lwrsby'cF* under tin psios and penilslos of perms, doll
() 1 am an employer providlnp workers' compensation covepfe for mw eirpleyeoe workin M
Inturanos m+rMe► - _'`� l �i C� . P Nweabol
1 set a cols proprieew and have se am wwkkp fir ane kr MW espodge
() 1 son a role proprietor, general convaetx or homeowner (dr I rate.) esld keve hkW do
certtractors listed below who-have t14 fob workers' ooarpntors>a pOMM
Cewtretaw InwretaEs ComtpegR Nttntbor
Conveaw Insurance Compatry/Fo N
Contractor Inmmance Company/Poft Nutabor
O I am a homeowner performing all the work myself.
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Hart wrrrrwe+e s ao s dd emwie in am kne eta STOP WORK ORDER am afar of S tOOAo a an anima me.
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Signed ch day of
L
YTT
:iceiss i Fennitlee 6l da, "� Deparsn.e t
e inf Eoare.
Seiectmem Office
=eslth Leparmer.:
7.
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