90 Federal handrail21092020 Date Stamp
Salem Historical Commission
'20 INASHINGToh S,,_REET SA{,-11 „SSACHUSEI-S 0197C For Office Use Only
9711)h?�-^685 FAX;gTR. 40-0::,
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: r I(r, 5 /(c
Name of Record Owner(s): C&v v'i c V4 LAC,t s C 6 b o �
Owner Mailing Address: `1 ° �C-C t-
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
AVC, C�0�y
Name of Applicant: LA l S ❑Owner Contractor❑Tenant ther:
Signature: 1 Date: I
Tel. #: 7a7 E-mail Address: k e I( " C! P'k R5 L4ir-5 '6.4 ('L°t
Certificate will be mailed to the owner unless otherwise indicated here/
Certificate should be marled to: Name ` -r
Mailing address: 'TV We S City: O f r t,,-N State:_Zip:
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