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PLAINS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Building Permit Application For: LacatiOO of iluilnlng 3 y bone �L v�
'(Circle whichever applies) Roof.Reroof. I iding,Construct Deck, Shad Pool '
Additio teratio /Replace,Foupdation Only, Wm*Wg
Other
PLEASE FELL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the IRRWor of Buildings.
The und"W"d hereby applies for a permit to build"rding to the •following specifications:
OwawY Name Contractor._ C. M 0-,,)d i ca 1 n c, ' L gat
$heel J'�7T/A t G V IMP /S L L GQ Clty�f.(l� street_ lLr LL" c y 65(e r.Z
Stau✓h� Phone o State Al, /J Phone( 79/) $0-0 — c(3 c/
Architect: City of Salem Licit
Street Ciq' State Lk#Y �83 �/ IIIP#
State Phone ( ) Homaawaers Exempt Formes no .
Strtsemm: (please cirde) Single Family Multi Fntnil _6zOther
Estimated Cod of job S U U b- W
Will building confirm to law/dyes
Adtestosl�p�00
Descriptiaa of work 10 be dow— AZ /4) (,U/ , `c 1,J1
Drawings Submitted:_tea no Mail Pe ' to:
S�z �OZ
tru?Gu L �
Sipa M of Applicatba,SIGNED UNDE� PEy
L PERJURY
CONSTRUCTION TO B . OMPLETED WITHIN SIX MONTHS OF PERMIT ISSUED DATE
Daimt ltent use only: Per,*# . Zoning Mwfi-ot
T
Permit fee S
COHIMTS:
�P/li10r/ �ON �Oh ✓ �'f� Cd� �:1� �. m
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