122 Derby Street - C of A application - paint colors Date Stamp
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Salem Histarical Commission
120 WASHINGT7ON STREET.SALEM.MassnrHUSMS 01970 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 El Other
District: WDerby Street []Lafayette Street ❑McIntire ❑Washington Square
Address of Property: 1AA Zele4W
Name of Record Owner(s): d U �, 7C[J
Owner Mailing Address: 19
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Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Appli t: ,iGrJ Owner❑Contractor❑Tenant❑Other:
Signature: Date:
Tel. #: .S= E-mail Address: t/ q7�� ,(�_ Ali-
Certificate will be mailed to the owner unless otherwise ind' ated h re:
Certificate should be mailed to: Name
Mailing address: City: Stat*Zip:61491
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