82 Derby Street Date Stamp
RE EIVED
R
F B 10 2016
Salem Historical Commission DEPT. OF PLANNING &
OMMU ITY DEVELOPMENT
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970 For Office Use Only
1976,61&6665 FAX 1976i 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: oDerby Street ElLafayette Street [vlclntire []Washington Square
Address of Property: 8c2- De-RwH Sr
Name of Record Owner(s): QaQ.r,: Le<,s 4o�js , 4- 1 eLu renCF 01�1
Owner Mailing Address: 1-3 /Wc/c V4 4�4z- m,-r 01 9 8-)
Description of Rork Proposed
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Name of Applicant: /lo } Q r r ❑Owner®Contractor❑Tenant❑Other.
Signature: x, �a� ej Date: a /R l;ply
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Tel. #: 973r - 36es- S'LY6 E-mail Address: &V F r GT;r)a}cr AV ?je,1100. e 7
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name A.'Ae,f /S S� -
Mailing address: le 7 /1 Sr", l fr City: 6-,&, c\4,k State:,V47ip: SLY
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