19 Broad St - C of A application - Certainteed Landmark architectural shingles .� s (9 �
Date Stamp
RECEIVED
MAY 2 9 2018
DEPT. OF PLANNING &
Salem Historical Commission OMMUNITY DEVELOPME T
120 WASHINGTON STREET SALEM.MASSACHUSETTS 01970 For Office Use Only
(978)619-5688 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 Ef/ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street Ej54clntire ❑Washington Square
Address of Property:
Name of Record Owner(s): '►-C k v �_S
Owner Mailing Address: /W- 0 7
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Appli -. L� (� .f Owner❑Contractor Tenant❑Other:
Signature: Date:
Tel.#: — E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: