6 MALL ST - BUILDING INSPECTION DATE: I Q to
Citp of '6bate Ti, 1R&S!5arb 15Ettq
PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building
Building PermitApplication For:
'(Circle whichever applies) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
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 according to the following specifications:
Owners Name: Contractor: (�T
Street A Street City
Stat Phone ( ) State Phone(� ) a'p /
Architect: /V�/� City of Salem Lic4 L
Street City State Lic#1 >�s�9 HIP#
State Phone ( ) Homeowners Exempt Form _yes no
Structure: (please circle) Ingle Family, Multi Family# Other
Estimated Cost of job S . , D/Jl�
Will building confirm to aw?- y ves no
Asbestos?_yes=no .
Description of work to be done:
Drawin a r r 5 no Mail Permit to:
Sif fturreoYApp ation,SI ED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO B&iCOMPLETED WITHIN SIX(6) MONTHS OF PERMIT ISSUED DATE
Department use only: Permi{#T Zoning Map/LotT_
Permit fee S
COMMENTS:
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