16 River St - C of A application for rear window Date Stamp
IV
NOV 17 2017
Y CPT. OF PLANNING&
Salem Historical Commission CO 'MUNITY DEVELOPMENT
120 WASHINGTON STREET.SAI OR' I+necnr—Iccrre n, -h 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 Alteration
❑ Demolition ❑ Painting ❑ Sign �] Other
District: ❑Derby Street ❑Lafayette Street EMcIntire ❑Washington Square
Address of Property: (� IZ w er Q{
Name of Record Owner(s): V-eVm $ t' 6e c4u �Aav,kens
Owner Mailing Address: i 6 14v c r S+
Description of Work Propose
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Applicant: KeV(A V ae\c ns ®Owner❑Contractor❑Tenant❑Other:
Signature. _ Date:
Tel. #: E-mail Address: evvicti( 6? KeVinkc4okeins.Com
Certificate will he mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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