13 Warren Street - CofA application for chimney removal Date Stamp
C.
Salem .historical Commission
t�WASHINGTON STREET,SALEM,MA9SAGHUSET S 01970 For Office Use Only
(978)619 WS FAX 1978)740-0404
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 [3dcIntire ❑Washington Square
Address of Property: 3 Locre-� J4Te`
n /6' ,
Name of Record Owner(s): l (T�l -r-'�
Owner Mailing Address: M 4 d I`1-76
Description of Work ProRosed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Applicant: ric4cr, (5-LJMCA.\. [56wner❑Contractor❑Tenant❑Other:
Signature: :Z2EDate:
— v E-mail Address: rY I0 LU 11K c r^b A
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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