100 Derby Street application for new wood entrance door Date Stamp
R EIVD
DEPT. FPLANNING &
Salem Historical Cotnmissiohl mMUNI V DEVELOPMENT
120 WASHINGTON STREET SALEI,t MASSACHUSETTS 01970 For Office Use Only
(978)619-5685 FAX(978)74rt0404
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: ,E�IDerby Street ❑Lafayette Street ❑Mclntire ❑Washington Square
Address of Property: /Q D T) F ?1 6 1/ �,
Name of Record Owner(s): M F1 "r I N F A01) P}t I t.t P
Owner Mailing Address: Z 8 C- A R L.70^1 J T 4 L Ef
Description of Work Proposed
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Name ofApplic t: �8 11 - ttER l�Owner ❑Contractor ❑Tenant ❑Other:
Signature: Date:/ 22 41 Z a/6
Tel. #: 9 7�- '? - - r 6J
E-mail Address: Tin// Sop?H1L ConC' ° ` r
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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