159 Derby St - C of A application - sign Date Stamp
CEIVED
Salem isltofical Commission PR 2 7 2018
120 WASHINGTON STREET,SALEM.MASSACHUSETTS 01970 DE OF r Only
(978)619.5685 FAX(978)740-0404 COMMU DEVELOPMENT
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 ❑McIntire ❑Washington Square
Address of Property: 1 S-9 17tF YL 15" f T-
Name of Record Owner(s): LA L � A TW(A 0
Owner Mailing Address: l e Y N u W qc L Y tJ O AAA Q f 4 d L
Description of Work Propose
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Name ofA pli ant: I LA` {1-t"t M 010"wner ❑Contractor ❑Tenant ❑Other:
Signature: _.- Date:
Tel. #: y �_ £T Y 3 ` 2 3 E-mail Address: A ti /+t2 T IU I ,4}y,-
Certificate will be mailed to the owner unless oth 2ise indicated here:
Certificate should be mailed to: Name L -4�r/
Mailing address: LYr-0if wg Y L y �✓A,' City: L- V" W State:"-t—Zip:'o070