311 Essex St - C of NA application - paint and repair dormer trim Date Stamp
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Salem Histofical Commission DEPI. OF PLANNIING 8..
COMML)AITY DEVELOPMENT
120 WASHINGTON STREET 541-E M 1AASSA,04U For Office Use Only
FAX(97BY740-0404
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:
El New Construction ❑ Moving F1 Reconstruction ❑ Alteration
F-1 Demolition Painting Ej Sign ❑ Other
District: E]Derby Street []Lafayette Street [3Mclntire DWashington Square
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Address of Property: "--
Name of Record Owner(s): 1-2 kayak c' e_
Owner Mailing Address:
Description of Work Proposed
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Please type or print clearly.Attach ad&hibnal sheets, as necessary.
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Name ofAppjica�: F]Owner 2qContractorF1TenantE]Other:
Signature:.. Date: L 'I
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Tel. #: 2,3L r_L636---)—E-mail Address: Wyl 0 OWA'1,9rb,2_at� (
Certificate will be mailed to the owner unless otherwise indicated here: rj
Certificate should be mailed to: Name
Mailing address: City: State:—Zip:
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