16 Kosciuszko Street - C of A application - windows, paint, repairs Date Stamp
3 RE EIV 0
� .
Salem istmical CommissionF B 12 2018
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 DEPT OF I &
(978)619-5685 FAX(978)740-0404 Comm U + Y
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:
0 New Construction 0 Moving 0 Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street OLafa, ette Street ❑McIntire 0 Washington Square
Address of Property. p c V j t
Name of Record Owner(s): ,
Owner Mailing Address:
Description of Work Proposed,
Please llpe OFPMit clearlf:Attach addidollal sleets, as Jz
ssarj:
�i/`t� /��/� v a� C �° U /� a/t' !? C'
�,� !�� ea
AY
z'
J7
Name of Applicant: ' W;rvn err ❑Tenant ❑Other:
Signature: - - -- Date: d /,
Tel. #: � 3 Y E-mail Address: ,%4e `Z 4iUG
Certificate will be mailed to the owner unless otherwise indicated here: L
Certificate should be mailed to: Name—
Mailing address: j t f e f J City: /ter•! StatV. Zi &/±