1 Block House Sq - C of A application - paint colors Date Stamp
31 2t
DEPT. OF PLANP `:vC, :&
MMUNITY DEVELQF%IE:;jT
Wein Ili-ow-iral Commission
r: 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 Ig] Painting ❑ Sign ❑ Other
District: XIDerby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: I_ bi D C V, I5c, 3 -�c-e -
Name of Record Owner(s): �K2- V ; (�G��r Iff
Owner Mailing Address: qsc Sy 2Ki
Descriiition of Work Proposed
Please l►Ipe or plinl clearly% Auach ilc](lllnurll sheels, as rlecessari
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Name of Applic nt: �uZ V r'���t''�`Pa I []Owner❑Contractor❑Tenant❑Other:
Signature: �'�^� Date: �' l' �' 7
Tel. #: 7 g g g E-mail Address: O x- m S r?
Certificate will he mailed to the owner unless others-vise indicated here:
Certificate should be mailed to: Name
Mailing address: __ City: State:_Zip:
TV- ej 114�
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