44 HARBOR ST - BUILDING INSPECTION fl�N81Ntl6t�E I1rD APPROVED 13Y TW
JMSPZ=M PWR W A.PERW 11EWG GRANTkD
CITY OF SALEM
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Permit to: No
t
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reif, Install Siding, Conwuct Deck, Shed, Pool,
Repair , Other
PLEASE FILL OUT LEGIBLY 6 COMPLETELY TO AVOID DELAYS IN PROCESgM
TO THE INSPECTOR OF BUILDINGS: '•
The undersigned hereby applies for a permit to build accordGig,to the following
specifleations:
Owners Name Teo 4 e n Q 2,�-Jc 0
Address A Phone 9y 14,zAmn s,—,eaar, 5,9/ . ( 1
A►chiteces Name
Address d Phone ( 1
Mechanics Name Pe -,fL G .
Address A Phone /i a D kx,,4� fir. ss✓-, ( I
WhW Is tha pupm m WOW
momm of rwarg9 w oo A Ae,La n a abre0 ,for how many t.nw.7
wa bLikkg coaonn to hw9 Agmft t4 (Ze4
F.WWW cm /s om o CRY Lkww r 179 81010 N C S o 1 /
ram t
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re of Applicant
SKIINED UNDER THE PENALTY'
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMITTO: Ana, Gee,),'e,e /l cocoi)6l g(4 c'cat r. .rlg.oyao
NO
APPLICATION FOR
PTO
Re
71
LOCATION
PERMIT GRANTED
1� 19
APPFrD
INSPECTOR OF BUILDINGS
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wkbA principal place of bmbsas aes
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do here:by•cerdy under t)w pubis and pesiides of poi.wy, chm
X Ia an emploYe►providing workers' compansad" coverage for my employees waking 0*0
Insurance Company Peft Number
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1 am a sole proprietor and haw so one working fdr me bn any ooecky.
Q 1 am a sole proprietor, general contractor or homeowner (drde ono) mad how hid the
concraeton listed below who•baw the fcillvwisg workers' eompenseuien pe6desi
Comraaw Insurande Compamy/Poft Number
Conaaaor Insurance Company/►o Number
Comracror Insurance Company/Policy Numbor
0 1 am a homeowner performing all the work myself.
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