6 Cambridge Streed C of NA paint 0 ra
4 bs'
Salem Historical Commission
120 WASHING':ON STREET,SALEM.MASSACHUSE7TS 01970 For Office Use Only
{978)819-5585 FAX l9781 740-0404
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
ursuant to the Historic District's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance,
pplication is hereby made for issuance of a Certificate of Non-Applicability as described below for:
New Construction ❑ Moving ❑ Reconstruction ❑ Alteration
Demolition ❑ Painting ❑ Sign ❑ Other
)istrict: ❑Derby Street ❑Lafayette Street rMclntire ❑Washington Square
Adress of Property: b -
fame of Record Owner(s): VfL, 7L,& &,eUl
►weer Mailing Address: �0-�-� � +/1".
Description of Work Proposed
Please type or print clearly.Attach ad&donal sheets, as necessary.
KI f&�nl 4k SlA1r�l [� 6�✓ ) C �✓r I'xTL 4-6rO
lame of Applicant:V ❑Owner❑Contractor❑Tenant❑Other:
ignature: Date: 1 19 2,6 1 k
el. #: 61 � - 65z� E-mail Address: {�lO
'ertificate will be mailed to the owner unless otherwise indicated here:
'ertificate should be mailed to: Name
failing address: City: State:_Zip: