12 Winthrop St - C of A application - paint colors Date Stamp
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Salem istofical Commission u� 312018
DE T. OF PLANNING&
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 COM UNI�� a'q
(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 ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition Painting 0 Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ®McGuire ❑Washington Square
Address of Property: m Srite A�6r+� Ma c�4ao
Name of Record Owner(s): KAt o iku AIII pW /-C,%,4 #A*
Owner Mailing Address: st .►Ig n,,
Description of Work Propose
Please t1pe or prh2t clearly:AttacL ad& olial slieets, as necessary
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Name of Applicant: VIII Wo ac a 0%G49.O W 1t Owner ❑Contractor ❑Tenant ❑Other:
Signature: Date: al 1 s) l,t _
Tel. #: -1 -z► '9 S 1 E-mail Address:-911mil
.-4ificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: NameSot- M-Vtftavat
Mailing address:-ate w -ra !1111111 MCI City: sA"U,M State:�4Zip: ot,70