19 FRANCIS RD - BUILDING INSPECTION fLaM611M�6T�E flla-fi D APPROVED BY T+IE
JdSrPMIDA PIWIR TD.A.PERLAIT MNO GRANTED
^\ ,\ CITY OF SALEM h
No, JV -� '� Date
Is Property Located In / Location of
the Historic Dlstrlct? yak--No_ Building I�
Is Property Located In
iM Conawvatlon Area? Yes No
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 PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications: /
Owner's Name V, doff NS a/�
Address & Phone I M 7
Architect's Name l�aM e e iv o
Address & Phone i )
Mechanics Name
Address & Phone
What is the purpose d bWWWC?
Materiel of butldhrq? tl a dwelft,for taw many IamYies?
WN buUdit cordon to law? Vc5 Asbestos?
Esftaattad cod I� 5 d b Gty Ucwm• N A State Licwm N
Baaa Fapruvegant
Signature of A00icant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
NsTW�L � X �
MAIL PERMIT TO:
r ,
T.r
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No.
APPLICATION FOR
PERMT TO
LOCATION,,,
PERMIT GRANTED
2.0
APPROV�D
INSPECTOR DF BUILDINGS
CITY OF SALEM
BunDwri DFPARTiv M
liMaMM LICENSE EXEmy110N
Flew Pdo
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TEL EMOM
FnSF,ir MAa M ADDREM
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HONIEOWMVS SIGNATURE
APPROVAL OF BMDING DWECfOR
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HOMEOWNER'S EXEMPTION
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