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Salem isto��Lca E..o��Z]�Zt,S,�ion WMUN TY DEVELOPMENT
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619-5685 FAX(978)740-0404
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 ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition Painting ❑ Sign ❑ Other
District: ❑Derby Street 0Lafayette Street WMcIntire ❑Washington Square
Address of Property. & S
Name of Record Owner(s): p /i K -F 1h v r ,t y
Owner Mailing Address: y �,V1w S
Description of Work Proposed
Please tape or prvlt clearly.Attach ad& oral sheets, as necessary.
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Name of Applicant: a r i h ` 'f'+ )?6wner ❑Contractor ❑Tenant ❑Other:
Signature: - Dater 3
T #: k�`�' - O S�� E-mail Address: S �� `�,
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: