11 Orne Sq - C of A Application - approve fence after the fact Date Stamp
Salem Histofical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETfS 01970 For Office Use Only
(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 ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property:
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed
Please lipe orpru2t clearly:Attach addidottal sheets, as rtecessaty.
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Name of
❑Owner ❑Contractor ❑Tenant ❑Other:
Signa re: Date:_ , -
,l # - o E-mail Address:
t-ertificate 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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