40 Flint St - C of NA application - repaint inkind Date Stamp
CI E
JUN 1$ 2019
Salem Histon.Cal .ommissI10111 D PT. OF PLANNING &
TY DEVELOPMENT
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APPLICATION FOR A CERTIFICATE OF APPIIWRIATENESS
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 P�clntire ❑Washington Square
Address of Property: D �� A 7G
Name of Record Owner(s): �1 f�
Owner Mailing Address: / .✓ �� /o r' G/C ��J
Description of Work Proposed
Please t)pe orprint cleajlr: Attach a(lckional sheets, as nec•essarrl.
Name of Applicant: T powner❑Contractor❑Tenant❑Other:
Signature: Date: ��
Tel. #:��—� S E-mail Address: l°ap��
Certyicate will be mailed to the owner unless others i indicated here- /7
Certificate should be mailed to: Name Z��
Mailing address:� � / T= S _ City: _ State:�ip: �1
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