14 Cambride St - C of NA - carriage house repairs DL[tc Sianip
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Salem Historical Commission
For Office Use Only
APPLICATION FOR A CERTIFICATE CIF 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 1:1 Alteration
Demolition Painting Sign [3 Other
District: 0Derby Street E]Lafayette Street [:]McIntire E]Washington Square
Address of Property: 14 Ce. V-1,16v (,fit
Name of Record Owner(s)., M Nrvr "Vi 4-r
Owner Mailing Address: rk --. o,e-- I X AA fi v l-It 4 c d-I).�j
Descriotion of Work Proposed
Please type orpr&it clearly.Attach additional sheets, as necessary.
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Name Of A Zant. ie," f S1 4c S -]Contractor[]Tenant 00ther:
[:]Owner[_
Signature. T 1 7-7
Date:
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Tel. #-, E-mail Address: [)<- CV (-
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: city,
State:—Zip: