107 Federal Street application Date Stamp
� .
1N3Wd 13A30 A11Nf1WW00
ON NNVId d0 1d3O
Salem Histm cal Commission Q 3 !� Q
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970 Or O ce se y
(978)619-5655 FAX 1978)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
0 Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette S et %McIntire 0 Washington Square
Address of Property: 10 Frde
Name of Record Owner(s): t4c
Owner Mailing Address:
Description of Work Proposed
(� f Please type orprint clearly: Attach addiaoual sheets, as necessary. p
�r L « j,(`n-� -e w O� c4 t y w%t v. v w-- G `-✓�- F t S
p O V/ w t 0 " ` r 1 C4/l q .Py� P V'l W o or(0 dV�
Y0 Qua✓ c K -
in-e - J il
Z t^-S' w l v.o�o w f e c -Fo -•K - s
Name ofApplicaA,: j,), c o GdAwner ❑Contractor ❑Tenant ❑Other:
Signature: ate:
Tel. #: 9 -7 Y - 59b — S e E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
i Mailing address: City: State:_Zip: i