17 12 RIver Street C of NA paint y
�+ �+ Date Stamp
RECEIVED' �r
JUN 212018
DEPT. OF PLANNING &
COMMUNITY DEVELOPMENT Salem Historical Commission
120 WASHI,NGTON STREET SALEM MASSACHUSETTS 01970 For Office Use Only
(978)619-5685 FAX+9781'140-0404
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: ❑Derby Street ❑Lafayette Street [?(McIntire ❑Washington Square
Address of Property: -i- ?,,vex— 4 rf
Name of Record Owner(s): F (
Owner Mailing Address:
Description of Work Proposed
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Name of Applicant: e L6A e iL 21Owner❑Contractor❑Tenant❑Other:
Signature: ! Date: eo XZp t//8
Tel. #: E-mail Address: C. t�51'o n i
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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