13 Warren Street - CofH application for chimney removal r-
Salem Historical Commission
120 WASHINGTON STREET,SAiLEM.MASSACHUSETTS 01970
(978)619-5685 FAX(978)740.0404
APPLICATION FOR A CERTIFICATE OF HARDSHIP
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 Hardship for:
❑ New Construction ❑ Moving ❑ Reconstruction ❑ Alteration
C� Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street &cIntire ❑Washington Square
Address of Property: � S (,uc r(-A
Name of Record Owner(s): vc,\
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Owner Mailing Address: l Z i�1�,,,en 34-re� -S A^ tvx 4- 0(1q76
Description of Work Proposed:
(Please include required scale drawings,paint chips,catalog
�jcuts an
d/or samples
of'9material proposed, where applicable.)
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Applications must incl • " photos of • 1 • from public ways.
Name of Applicant: 4" C`Owner []Contractor ❑Tenant ❑Other
Tel. #: l 7 — ' C10- b E-mail Address: 00A.
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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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