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fL:MIB1AWST*EfKAN ND APPROVED BY TW
ASPEMB PBIGR TTl A PERMIT BRING GRANTED
F SALEM
CITY O
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Is PiMmy LoaMd in
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Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Remof, Install Sidktg, Construct Dm*, Shed, Pool,
Repair/Replace, Other
PLEASE PILL OUT LEGIBLY A COMPLETELY TO AVOID DELAYS IN PROCESSNG
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accortLmg.to the.folWaft
specifications: / / /
Owner's Name Cayll'a' 1 Z/ � / _/'Va✓/z
c Address A Phone //,o laj �eJ �(q7�1 a 73- 4c�/
Architect's Name
Address & Phone
Mechanics Name
Address 6 Phone / ( 1
wht is ar papas of b~ /�Alall` -/r wu 'z
M�MtI -of bdldifq? G/00n fi✓a wr r n a dwMMq,for faw,many hn1t4�o
VON' oonfomn to law? Anb W //hlTnawt�
Eftmiw ood ' oar i ay uantr« 0?60 y am um". O 7 a
C ��) . Signature of Applicant
SIGNED UNDER THE PENALTY'
OF PERJURY
DEESCRIIPTION OF
lF WORK TO/BE/�DONE // - ) l /�� /
V.
701
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0 I �a��! /h 0 7� ✓[5 LIGtG/ cT�CoHG� �lCC6✓ ,`/G�PIt S
MAIL PERMIT TO.
No.
APPLICATION FOR
PERrT TO
LOCATION
Al2
PERMIT GRANTED
A7
VfD
INSPECTOR OF BUILDINGS