19 Broad St - C of NA application - repair 3-tab roof 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 ❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign Other
District: ❑Derby Street ❑Lafa ette Street �tire ❑Washington Square
Address of Property: / �- Z-
Name of Record Owner(s): 1 jJ
Owner Mailing Address: ` 76
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Description of Work Pro nosed
Please type or print clearly.Attach additional sheets, as i-tecessaty.
Name of Applica 00wner❑Contractor Tenant❑Other:
Signature: Date: /
Tel. #: E-mail Address ' ll/L//J �'✓n ,�,d �
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address:_ City: State:_Zip:
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