43 Chestnut St - C of A application - minisplit, brick repointing and window restoration (002) Date Stamp
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:
❑ New Construction ❑ Moving ❑ Reconstruction E6 Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: f; G1qe44kut s tvetr
Name of Record Owner(s): e19 N MCA J W i N a t,4 C
Owner Mailing Address: Cke4tt"ut OCG f
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary:
o A G Gb 14 U►�}' �'` ��1 e- W's �I � P G b6 G6 W CG dL � •
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Name of Applicant: 4C�'` S `t s ❑Owner❑Contractor❑Tenant they: Aw 4j•
Signature:I Date:
Tel. #:. E-mail Address: heto& e
Certificate will be mailed to the owner unless othe yy'�ise ind' gted here:
Certificate should be mailed to: Name ZH N T r`t A &)l
Mailing address:_3 Gkee-L."t 15+-. City:54('.14A State:_Zip:
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