10 Chestnut St - C of NA application - 3-tab shingle MIFT
RECEIVED
is
� - APR 05 2018
Salem Historical Commission DEPT. OF PLANNING &
120 NJASFi!NGTON ST�ESTREETSALEt1f.MASSAd}-3LSETTS 01970 COMMUNITY DEVELOPMENT
i978j 615-568 FAX(9781 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 ❑ Moving K Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street McIntire El Washington Square
Address of Prope 0 C/I-cf
Name of Record Owner(s): /'/�/r�co��� ��''ClVfs "f' G�1.,-e �7-�r'�/-►-P
Owner Mailing Address: /0CAP,-A,;l Sr
Deserintion of Work Proposed:
lF-. -. .
Applications must include photos of existing conditions, taken from all public
Name of Applicant:/ ' zr1)A Spa Vr Owner ❑Contractor []Tenant ❑Other:
Tel. #: -)9� - 9 9S� �� E-mail Address: a/S�a/l /� S�`/'Avlf �' �/'�u,
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: