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Salem Historical Commission ti,°O �� �Q
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970 ��`��/ ��
978)619-5685 FAX i978i 740-0404
APPh %`PAP
APPLICATION FOR A CERTIFICATE OF
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 ❑ Sign H' Other
District: []Derby Street ❑Lafayette Street LUkIntlre ❑Washington Square
Address of Property: 9'�L /ifdotcjp
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Name of Record Owner(s): � 6V 0 4 LY Cvz l,; / ' VSj �Cac�el ����eK �-► ,e,� � �
Owner Mailing Address: ST.
Description of Work Proposed:
We A,t�, keGhTv1�' r�?vr �-e C ✓A4e,.t- wd&4 !—mCe Je,,� AeP/kLe � AaC`�crXXl�
can (�� P/9/?,L, / v/- &q [� Sr: I✓
S'a Nou Ll z,)✓)lApplications must include photos of existing�
conditions, :a:y:s�.],
Name of Applicant: /1 4 /eJ +-,,. []Owner ❑Contractor []Tenant eOther:
Tel. #: f111 ,S�l�— �t 3 y E-mail Address: A0 C4 /i e-9 m J of d f v -H
Certificate will be mailed to the owner unless othe, Rise indicate here:
Certificate should be mailed to: Name a. 4,�e e_4 eRm
Mailing address: We X 4S/. City: State:_Zip:
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