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pLI/16AWTSEfmag4 4a APPROVED BY THE
amiwx B P +WR TEA P.EBWr$EWG GRANTED
• CITY OF_SALEM
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Is Pwp"LOWN to Location of
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BUILDING PERIAR APPL=TION FOR:
Penntt ON
(Ck w whiotwvor apply) Roof. I" Siding, Cons W Dock, Shod, Pool$
PLEASE FILL OUT LEGIBLY i COMPLETELY TO AVOID DELAYS W PROCESSING .
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
simcdcations�
Owner's Name Qayed „MaWiAnC Ke_rnP. 6aim (mar one„
Address aPhone la, fkaxn* s S+' ia�gl7ciI -353sr
ArotdtWs Name n,IcL
Addrees A Phone j I
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THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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No.
APPLICATION FOR
PERWr TO
LOCATIO/N/
PERMIT GRANTED
APP OV�D .
I OR OF ILDINGS __