23 Warren Street - C of A application - fence RE
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DEPT. OF P
ANNING&
COMMUNITY
VFLOPMENT
Salem HiStorical Conn-nissn'011
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 foi:
❑ New Construction Moving ❑ Reconstruction Alteration
Demolition R Painting ❑ Sign ❑ Other
District: ❑Derby Street 1 ,❑Lafayette Street cintire ❑Washington Square
Address of Property:
Name of Record Owner(s): ►] aL UelvVI S c'Y'C' -
Owner Mailing Address: wi V e" 2L - ;AA V U
D smption of Work Propowd
Please type or print clearly.Attach additional sheets,as necessary.
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Name of Applicant: wne Contractoz❑Tenant❑Other:
Signature: Date:
Tel. #: 01 _�*t E-mail Address:
Certificate will be mailed to the owner unless otherw'a 'ndic,�te
Certificate should be mailed to: Name 4c`�
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Mailing address:7i' v y a_ll I�' fi City: �" `'� State:_Zip:
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