12 Broad St - C of NA application - 3-tab roof }
RECEIVED
' SEP 10 2018
• DEPT. OF PLANNING a
Salem HistoricalCommissio cOMMUNITY DEVELOPMENT
129 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970
=97$j 6 i 9-5685 FAX(976)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 ❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign Other
District: El Derby Street El Lafayette Street V'McIntire ❑Washington Square
Address of Property: q- �K O A D S —r ',5/ %!E/4 M,4 al q
Name of Record Owner(s): /� 0 1 �e d a
Owner Mailing Address: �- O �4D ST
Description of Work Proposed:
o
conditions,Applications must include photos of existing
all public ways.
Name of Applicant: A/ /�!`� eOwner ❑Contractor ❑Tenant ❑Other:
�.1. #: E-mail Address: e Oh 1 OLh0U - C0�
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: