application for 110 Derby Street - paint chips ' Pate Stamp
4.
Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
(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 0 Moving 0 Reconstruction ❑ Alteration
❑ Demolition �,' Painting 0 Sign ❑ Other
District: Derby Street ❑Lafayette Street ❑McIntire 0 Washington Square
Address of Property: 110 f-0�&f S',2G C( .
Name of Record Owner(s): � � L� j�j j .[ t\3
Owner Mailing Address: e E: T-
Descri tion of Work Proposed
Please lipe orpmit clearly:AttacL ad&hronal sheets, as 1lecessaly
S-s -. -ctc �cam( �.. -O -� cc�(Ory Gc s
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Name of Applicant: Pamdc'- -r✓-lOwl Ppwner ❑Contractor ❑Tenant ❑Other:
Signature: J , V, Date: 14 N
Tel. #: I 6D6 �lt-�i - E-mail Address: 1606 e- 1 CLOvD . GD rA i
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name { c-•0 f`�j
Mailing address: I I Q •%y, b city:
—��_ ty:5Abc-Nl State:N1A-Zip: 01 9