19.5 Broad Street - C of A application - repaint door and new lock set (002) Date
R G E I `AID
PR 24
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DE T. OF PLANNING &
Salem Historical Commission COMMUNITY DEVELOPMENT
120 WASHINGTON STr- SALEM MASSACNL'SET For Office Use Only
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
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 Non-Applicability as described below for:
New Construction Moving Reconstruction Alteration
Demolition Painting R Sign Other
District: ❑Derby Street QLafayette Street DIcIntire QWashington Square
Address of Property: IC/'6
Name of Record Owner(s): CA � ��t`
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Owner Mailing Address: L/ r S c-\if yl Ap
Description of Work Pronosed
Please type or print clearly.Attach additional sheets, as necessary.ar
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Name of Applicant: 1 C L G [gelwner QContractoC]Tenant QOther:
Signature: Date: V 2�
Tel.#: 71/-61 05�_-76] E-mail Address:__ }czCtc C 5 c ��� c4 i` - C o t
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:—Zip: