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Salem Historical Commission
120 WASHINGTON'STREET.SALEM.MASSACHUSETTS 01970 For Office Use Only
f978)619-5685 FAX(978)740-04C4
APPLICATION FOR A CERTIFICATE OF APPROPRIATENESS
ursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance,
pplication is hereby made for issuance of a Certificate of Appropriateness for:
New Construction ❑ Moving Reconstruction 2 Alteration
] Demolition Painting [] Sign 0 Other
)istrict: ODerby Street ❑Lafayette Street [�fMclntire ❑Washington Square
Adress of Property:
fame of Record Owner(s): >
►wner Mailing Address: 6 L -m�y' g,� '54 re eV 5.d t,, MA 0 ; 9-7 6
Description of Work Pro used
Please type or punt clearly.Attach additional sheets, as necessary,.
lame of Applicant: �� � `� QOwner❑Contractor❑Tenant❑Other:
ignature: Date: R a t
el. #: 61-7-- q I - 6 5 Z 5 E-mail Address:
ertifcate will be mailed to the owner unless otherwise indicated here:
'ertificate should be mailed to: Name
Tailing address: City: State: Zip: