2 Andover HC Application
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 re
Address of Property:
Name of Record Owner (s):
Owner Mailing Address:
Description of Work Proposed
Please type or print clearly. Attach additional sheets, as necessary.
Name of Applicant: Owner Tenant Other:
Signature: _____________________________________________ Date: ______________
Tel. #: E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State: Zip:
Date Stamp
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