238 Lafayette Street - C of A application - paint colors Date Stamp
10
Salem Historical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETrS 0107. For Office Use Only
E97 619.5685 FAXi9781740-0404
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 Paint' g ❑ Sign ❑ Other
District: ❑Derby Street 11- afa ette Street ❑Mclntire ❑Washington Square
Address of Property: G
Name of Record Owner(s):
Owner Mailing Address: 34 2-,o e-
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary
oovC,
Name licanO. f�-/ (J� ZOwneroContract or❑Tenant❑Other:
Signature: Date:
Tel. # - 3r 12t/r E-mail Address: ,r
Certificate will be mailed to the owner unless otherwise indicated her ln�
Certificate should be mailed to: Name � / d f
Mailing address: 23� �f� �// y 2- y City:��� State:_, ip.