21 Washington Sq No - C of NA application - restore windows Date Sump
Salem Historical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619.5685 FAX(978)74o-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❑ ❑ g ❑ ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire EgWashington Square
Address of Property: f f� cS &914—
Name of Record Owner (s):
Owner Mailing Address: 1�2 HA-
Description of Work Propose[
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Name of A Zleant: PownerE]ContractorFITenantF-10ther:
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Tel. #: Z E-mail Address: a�lG c�R (-e*lea�«��
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: