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165 Federal Application for Cert of Approp. Date Stamp Salem HistoricalComm '�Sion 9,9wASH€ GTON � F-ET SALEM, 01.971) For Office Use Only �37F�-,na�i.5r,,3Y 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 I":_ Moving - Reconstruction � Alteration E. Demolition L .fainting L Sign Other District: L.Derby Street Lafayette Street °<l..ntire _.:Washington Square Address of Property: 16 S 66-r:� L Sfi. Name of Record Owner(s): �I T-M A 6ot-7S7C5,J6J: U 0 VT I ��AXc.,l ©6S.AUi-—16-CS 0 i..? T� Owner Mailing Address: Description of Work Proposed Please type or print clearly. Attach additional sheets, as necessary. v n + C"e u,[- o� Z. G�r�r ►ems a'v. west Si cu- of k o, �- a (`ac t ! eta v" -f' o,1v. 5fi' �Cc c r Cam_ �- r I Name of Applicant: Ll A �. o -7�' t Ovine Contt'aCtor FTenant Other: Signature- Date: Tel. #: LEI?—Vic r 6� E-mail Address: �, I NDJ� Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name Mailing address: City: State:_Zip: ATTACHED DOCUMENTATION