5 HORTON ST - BUILDING INSPECTION IIAMIA"ST9E f4L*B-iW9 APPROVED BY 744E
MSAECXDR,PRIOR TD A PERMIT aENG GRANTED
v� CITY OF SALEM
No W
Date
Zoning District
Is Property Located In Location of
the Historic District? Yes No building
Is Property Located In
the Cor"MtIon Area? Yes No
Permit to: BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build accordwig.to the following
specifications: �y
Owner's Name 1141^ 9wil s l eo r—z o
Address & Phone If l
Architect's Name
Address & Phone If
Mechanics Name
Address & Phone
What Is the P HPoaa a budding? 2 FAbvi (y
Malachi of bu~ k-r o j) Ef Cnnf it a dwering,for how many tamon? 2
WIN buNdng cordon to law? Asbestos?
Estlmated cost SOO`� City Ucanw a N S D Z
��� �. t
Lie. I
;tgnature of Applicant
SIGNED UNDER THE PENALTY'
DESCRIPTION OF WORK TO BE DONE OF PERJURY
/Piow.ay�,_p � ��^ocn7` {g�tr�c �'{�� to ear®F 2 SF�e
P/J�i9 Q P / t-ta 4, L(j 14 /Dra-62L G)/'xrPfP 'PPS '�uu
MAIL PERMITTO: ' /G-p cs wpw�PYof D 1 �o J
j
I\ .
APPUCATION FOR
PERMIT TO
y7�,(rs
; LOCATI N c
PERMIT GRANTED
7 a 19
APPR qD
INSPECTOR O BUILDI S
L
07/22/2004 08:06 7815981843 DALELIO CONST CO PAGE 02
6W w
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�.eale &aim% Nasal- i 02111
Works"' COmperwtiau Won= AffWv*
r - I
aalelt a p place of basdnw M
i do bereby'ctnfp meet 01e PAW 00A pswahlr of pufwyl, shoe,
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Inrarenp mpitsp
" comp l�acu r LIC 769 - Z3 -2f
TONi,�
s
1 sot a sole PmPriemr said haw ns ono wo*Jw fir ttae In awy aprclq.
Q I sin a sob proprbwr, general twmiraeaw or homeowner (drde owa) and hrw lid die
coesfacw" lbted below who-have the foNowkg worlterso can evandon polldnas
ifel Insor>,ne+a eepatty/Raw NNXW�
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Contraea4r Insurance Conwasy/FalkyJAI
0 1 am a homeowner perforating all the Work myself.
eee�oaar a w...y of ei wnnaw.e Of lerwwm w am Qlaae M wra" awwt of ew bM.4 eawrore.wI a 0 an bass•more
aewwap ar raaae,a MW I - ' 21a of WA 152 can Mae u aw Wwaxi .at u4rm Hula sonmdn j of a how of so art I-Nx a aW er dM
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SIB der T
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s c itte building Department
ureroin� Eosrt
5elefsmens Office
�a�lth Geparmcnt
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07/22/2004 08:06 7815981843 DALELIO CONST CO PAGE 03
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