398 Essex St - C of A application - rear roofing RECEIVEYi Date stamp 1
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MAY 2 9 2018r3 - ,
r±EP?. OF PLANNING& -
COMMUk1TY DENELOPMEN
Salem Historical Commission
120 WASHINGTON STREET SALEM.MASSACHUSETTS 01970 For Office Use Only
(978)619-568h FAX(970)740-0404
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 El Moving Reconstruction� ppk� 0 Alteration
Demolition P
Painting Sign El Other
District: ODerby Street QLafayette Street � ire �wi�bington Square
Address of Property: ��$ ~5
Name of Record Owner(s): �-Tq.IFItL -L
Owner Mailing Address: E
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of�_ t• L erElContractor❑Tenant QOther:
Signature: Date:
Tel.#: % :fo -mail Address:
Certificate will be mailed to the owner unless otherwise Adicated here:
Certificate should be mailed to: Name
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Mailing address: 3gFS City�`�- StateML Zip:OWQ
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