6 Botts Ct - C of NA application - paint inkind Date Stamp
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Salem Historical Commission
120 WAS14INGTON STREET.SALE v1 MASS,%C LISETTS 01970 For Office Use Only
978)619-5685 FAXt97- 7,:I_7,1"'
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 0 Painting Sign Other
District: FIDerby Street ❑Lafayette Street , c McIntire Owashington Square
Address of Property:
Name of Record Owner (s): 1-0 0 K, -51P-118 N}J (
Owner Mailing Address:
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Applicant: DOwnerE]Contractor[—]Tenant❑Other:
Signature: _ Date:
Tel. #: E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: