4 HOME ST - BUILDING INSPECTION pL.AMj i6i qE f jE9 4 A9 AfhPROVED BY 'T44E
JdSPZCSOA PP"TDA.PEWIT UING GRANTED
CITY OF_SALEM
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BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
ReWiReplac:e, Other: -20 2'V ie!4 "
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS W PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name S/e&,,-
Address & Phone 7Z 37`//
Architect's Name f24
Address & Phone /5192G�✓�� . s / L 125Ldf�
Mechanics Name A44-41
Address & Phone
pp Oz-2t�
Whet Is the Pwposs 01 huilditq?
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asti Iopsoornc
C/ LAC. fJ Signature of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: CJ I� LfJI
No.
APPLICATION FOR
PERYR TO
LOCATION
�p RMIT GRANTED
20
t
AP ROVfM
INSPECTOR OF BUILDINGS