11 Andover St - C of A application - chimney cap Date Stamp
RECEIVED
AUG 15 2018
EPIC.OF PILAN010§4
Salem Historical Commission Co. IMUNUirY VVWftL0jPNLf_.N T
'0,N s-' BEM MAZ-3,'CHUSF I S 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:
El New Construction F__j Moving El Reconstruction Alteration
F-1 Demolition F-1 Painting F-I Sign El Other
District: E:]Derby Street ElLafayette Street D.K(McIntire E]Washington Square
Address of Property: olo vi- S �-
Name of Record Owner(s): JS,,,oP4-f- l v S nt &_LIj,1j k-eo,
Iq^&/, 0 /ee
Owner Mailing Address: /,-,-1 1 1*,4 0 70
Description of Work Proposed
Please type orp M* t clearly.Attach additional sheets, as necessary.
CI S'Z less CO/0440
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Name of Applicant: K OwnerE]ContractoroTenantE]Other:
Signaturez___'_'_�� Date:
Tel. #: �1_7-233- -7el Z_ E-mail Address: (3057_0/V,. /eCV7- 7 S-0— kMcv- Co
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: 11 A,,,16 ye,,- ST;,-e e city: StateAkip: �0
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