102 Derby Street - C of A application - replace steps Date Stamp
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of
Sale"' istolical CollZM s ' �pY 23 2019
120 WASHINGTON STREET,SALEM;MASSACHUSETTS 01970 V IN I oi)offi j4 0�y
(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 0 Moving ❑ Reconstruction
El Alteration
❑ Demolition
❑ Painting 0 Sign 0 Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire r
❑Washington Square
Address of Property: /d C�- —
Name of Record Owner(s):
Owner Mailing Address: 0 r��� ��> , 1,1
Description of Work Prowsed
Please ope or pm1t clearly:Attach additional sheets,as vecessarJ
�!�Ci� vJ�L � e•,_ e Q,.1 dC� •-C`•� ` w"��j��'c.ti�. � -�-C�S-�a v.L cv �1 ��
I ke
Name of Applicant: ��� �� ��`,� ❑Owner ❑Contractor ❑Tenant ❑Other:
Signature: -
�'' � Date: ?
l _ E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name—
Mailing address: f-- City: State:_Zip: