121 MARLBOROUGH RD - BUILDING INSPECTION " L
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CITY OF SALEM
No. Z( q 700� F;t�. "���\ Date 09 V 2 it
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Is Property Located In V Location of the Historic District? Yes_No Bu:Uding ) 2 1t
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Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(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 according to the following
specifications: -
Owner's Name S-tNit 1>wH- �I
Address & Phone u-�2L P,i30A-� h-H 01. 0, --q
Architect's Name
Address & Phone )
Mechanics Name
Address & Phone
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform to law? Asbestos?
Estimated cost City License # N A State License # "
po Home Improvement
Home
-- Lic. /
Signature of plicant
c r�ht 6 SIGNED UND R THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
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MAIL PERMIT TO: �;2t 1ti1 �—K,o �AII�H lam' ,
No. Z t q -zoc)
APPLICATION FOR
PERMIT TO
4 LOCATION
PERMIT GRANTED
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APPROVFD
INSPECTOR OF BUILDINGS
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