6 South Pine St - C of A application - building modifications Salem Histot I Commis
,tea sion
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:
New Construction ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: 5b[.�d"1 , Ri +,e.
Name of Record Owner(s): of 44 itj .fee rc
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Owner Mailing Address: 4 Ss u K, P1 tir S G 5ff � f a
Description of Work Proposed
Please 13j)e or print clearly.Attach additional sheets, as nece-ssazy.
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Name of Applicant: Lc- �e.� < < ❑Owner❑Contractor[]Tenant[ElOthe ✓I
Signature: Date:
Tel. #: °�71 71-11 f, E-mail Address: kc L- c�� 5l is • co ry�
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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