13 Warren Street application (002) Date Stamp
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Salem Historical Commission
120 WASHINGTON STREET,SALEM.MASSACHUSETTS 01970 For Office Use On1v
(978)619-5685 FAX(978)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 d Reconstruction [[� Alteration
❑ Demolition r1 Painting ❑ Sign ❑ Other
District: ❑Derby Street II ❑Lafayette Street" Evlclntire [:]Washington Square
W Address of Property: 3 CfrG/\ /�S� �a`t,�'ce�
Name of Record Owner(s): � �-t,
Owner Mailing Address: 53TCe.d-t s L=a
Description of Work Proposed
Please type or print clearly. Attach additional sheets, as necessary.
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Name ofApp ' C � downer❑Contractor❑Tenant❑Other:
Signature: Date:
Tel. #: E-mail Address:
Certificate will be mailed to the owner unless othdicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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