192 Federal Street - C of A application - architectural shingles and cornice trim EOfficeUse
Salem isto��ical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970
(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.-
0 New Construction 0 Moving 0 Reconstruction
0 Demolition ❑ Alteration
❑ Painting 0 Sign Other
District: ❑Derby treet OLafayette Street Amc Intire
❑Washington Square
Address of Property.
Name of Record Owner(s): 4 fa O
Owner Mailing Address:
Descri Lion of Work Proposed
Please IYPe orPrh2t clearli- Attach addidoual sheets, as 1lecessarj
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Name of Appli Owner ❑Contractor ❑Tenant ❑Other:
Signature:
Date:
E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address:
_ City:-- State:_Zip: