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19 Broad St - C of NA application - inkind replacement of 3tab roof Ne RE: C EED ,. JUL 27 2016 ` DE PT. OF PLANNING & Salem Historical COM UNITY DEVELOPMENT a seal Comm�ssi©a 120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only [97R1 R1Q-RRRS FAX 1Q7R1 7dn.nAnd 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 [El ReconstructioV ❑ Alteration ❑ Demolition ❑ Painting ❑ Sign ❑ Other District: RDerby Street Lafayette Street 1 cIntire OWashington Square Address of Property: � v Name of Record Owner(s): Aly Owner Mailing Address: 4-1,L, —7- e Description of Work Proposed Please type or print clearly.Attach addiliorlal slieets,as Necessary. I` ,pi 4 A- /7 pa, a '? C.'( 1 wner Contracto Tenant her: Name of Applic � �_�� ❑O ❑ ❑pt Signature: Date: Tel.#: 7_ S�j C�LI -mail Address:J -h)l (,1)l.� Q.) aYYI Cep . CYl Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name Mailing address: City: State:_Zip: