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Broad Street Cemetery application for new sign Date Stamp V . �' DEC 15 2011 Salem Historical Cornnrssion r- 7 0, 1`'1 N & 120 wASH�M1,rT^• •.r..... _-- ---__.-- - For Office Use Only APPLICATION FOR A CERTIFICATE OF APPROPRIATENESS Pursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance, application is hereby made for issuance of a Certificate of Appropriateness for: New Construction Moving ❑ Reconstruction ❑ Alteration ❑ Demolition Painting ❑ Sign ❑ Other District: ❑Derby Street ❑Lafayette Street rcIntire ❑Washington Square Address of Property: 5- C31 4 Name of Record Owner(s): C i-4• Q.� �,,,�. ,�.,,��-,�,,- 4GWWI M 1,6 s o Owner Mailing Address: o c� G�(� �- �bl e Description of Work Proiposed Please type orprint clearl`y�.Attach adch oval sheets,as necessary.f C �. *e<�`� .S�'� to CL'� L'--�2T d-Ct✓� L � `�� d' O ct�c�- �1��o `�'�- ^ Ln f J�� i CL` 1 l9V�©J Y'�C3. .._ �© J'-✓1.�.�- a� �7'©C1�.� � +-`�� ©:�v� 'F- J 1 S46r, C. clsa let" f � DPS Name of Applicant: M CCU Owne ContractoroTenan(�gOther:ASS .. DIP-. Signature: Date: )L - 1 l - a 11 Tel. #: - I - O�'� E-mail Address: 5 M CCe� °' S, A L m - eom Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name 11-1 LA c Cry l-A Mailing address: City: State:Zip:0 1� . ....... ............... .. .......... M� ft, N5 Offi-MA • MR, I MIRU'R"', A mmu OULD COLONY SIGNTMAKE RtS 73 Devonshirestreet, Provitlen.ce, Rho& Ind 02908 ESTIMATE OF COSTS jOb: 151;Z'Vk) ' CF K CC-14�7 h4,0 'Signed- - ---- Dated: qhq-6,pt7 a Tel.:(207)779-0707 e-mail: ouldcolony@aol.com websitc: www.ouldcolonyartisan.com