188 Federal Street Date Stamp
For Office Use Only
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 [S?r Reconstruction ❑ Alteration
❑ Demolition Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street RVlclntire ❑Washington Square
Address of Property: M A dex— --
Name of Record Owner(s): lies i;e—
Owner Mailing Address:
Description of Work Proposed
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Name of Applicant: e5ll C LltO ZE, Owner❑Contractor❑Tenant❑Other:
Signature: Date:
Tel. #: 1` '� -�' f' E-mail Address:
Certificate will benaailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name I C'
Mailin �`
g address: ___ ��l}'1. %„C� City: State:_Zip: