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J UPUMB PWR TD A PMIT J3EWG GRANTED
CITY OF_SALEM
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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, hsd)Pool,
RWair/Replace, Other
PLEASE FILL OUT L EOIBLY 6 COMPLETELY TO AVOID DELAYS IN PROCESSM
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accortLig.to the following
specifications:
Owners Name /!mil ct'-!z /Gt . su a c bo u_ g&- //
Address & Phone 2.-3 6-1-/1aws 9d/ (�7
Amhitects Name _
Address d Phone [ ) —
Mechanics Name /o S y 0),)0 do)orres
Address & Phone N l4 f
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Signature of Applicant
SIDNED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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APPLICATION FOR
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