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Salem Historical Commission
120 WASHiNGTON STREET.SALEM.MASSAGHUSETTS 01WO For Office Use Only
i978)619-5685 FAX(978J 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 lsj vlClntire ❑Washington Square
Adress of Property: 54r ta
Fame of Record Owner{s}: �s�►�+ c L'. t _
)weer Mailing Address: ^^�` `�� S �^ M l�
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary
����,c.,e, c.�•�-ter 5�.��le.� �., ��� �.�Ir a'� G►�-ye, i"�� �f���� ce�.�.� S�ti���-S .
Fame of Applicant: � � ❑Owner❑Contractor❑Tenant❑Other:
ignature: Date: -zo 18,
eI. #: ZS_ E-mail Address: L d Ca,,,
ertificate will be mailed to the owner unless otherwise indicated here:
'ertificate should be mailed to: Name
flailing address: City: State:_Zip:
4
Salem Historical Commission
120 WASHINGTON STREET.SALEM.MASSACHJSETTS 01W0 For Office Use Oniv
(978)619-5685 FAX)97Bi 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
District: ❑Derby Street ❑Lafayette Street �Iclntire ❑Washington Square
Adress of Property: , c54r`za
Fame of Record Owner(s): s�- �"
)weer Mailing Address: 6 6, ` 4� S ki vw M A Olj d
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
lame of Applicant: �-o L. Sm 196"r❑Contractor❑Tenant[]Other:
ignature: Date: 5 9
el. C S�j E-mail Address:
ertificate will be mailed to the owner unless otherwise indicated here:
'ertificate should be mailed to: Name
Zailing address: City: State:_Zip: