Application for CofA for 328 Essex Street 'i �1 Datee Stamp
; at Imo.
OO N:.,,
Salem Historical Commission
120WA9HINGIaN 1STREKT.s'Aven4.E+as^oACF{uset`rfia;am For Office Use OKIY
FAX{J?8)7400404 -
APPLICATION FOR A CERTIFICATE OF APPROPR[A'I'ENESS
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 El Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: 32.b' ef:3 sQ4 S'T
Name of Record Owner(s): hpac-fi-7- ) t® 1
Owner Mailing Address:
Description ot'Work Proposed Oitice, amw-lzmveis
Please ljpc orhrznl cleatlr.Attach additimmisheets, arnecess;mv
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Name of A Jicant: tttvi�ild _ ❑Owner❑Contractor❑Tenant❑Other:
Signature Date: ri - ) 2
Tel. #: E-mail Address: Jpr r-V C�,I IV Nr Gt -o Cv. 5W L7,o&) U r-t
Certifecate will be mailed to the ott ner untess otherwise indic4itect 1�ere: o
Certificate should be mailed to: Name c4n n r r C t uY£vu� z u U `
Mailing address: �i q avd�.i e- ri City- � " Stat Zip: � �1