162 Federal St - C of A application - paint colors Date Stamp
RECEIVED
_ t AY162018
~" DEP . OF PLANNING &
COMM NITY DEVELOPMENT
Salem Historical Commission
12;WASHINGTON STREET SALEM MASSACHUSETTS 01970 For Office Use Only
(9781 619-5685 FAX 1978)74C-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 ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street , %4clsttire ❑Washington Square
Address of Property:
Name of Record Owner(s) 4.Zz;,
Owner Mailing Address: 17 o
Description of Work Proposed
Please,3pc orpjm' t clearlt _Attach additional sheets; as necessary
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Name of Applicfn ❑Owner®C'ontractor❑TenantOther:
Signature: Date: � �'
Tel. 4: 1 E-mail Address:Certificate will be mailed to the owner unless otherwise indica l h e:
Certificate should be mailed to: Name' s 1.:e_1
Mailing address:_ ' %o � .�7 City: State: ip:
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