6 South Pine - C of A application - skylight Date Stamp
Salem Historical Commission
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:
M New Construction ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: '+ ,yz" n, l l l P 5�/ee
Name of Record Owner (s): 0 A e VJ 1� V p! J c �, a (,, M-e v v i
Owner Mailing Address: 6 1 U
Description of Work Proposed
Please type orprlrlt clearly: Attach additiornal sheets, as necessary:
ve v V-, I &I "I r 1 S n t^ b e c k e
I,vt s l� v L_ F
be V1S1 f 6 (�J � � � (,IC. Lk�P�� 1 `[L'
Name of Applicant: 4`7 efc ❑Owner❑Contractor❑Tenant[DOtherA/c t fell
Signature: Date: �,� ' I, Z' u'L,4,
Tel. #: E-mail Address: [AP yi s c
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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