19 Broad St - C of NA application - rebuild stairs and replace storm door Date Stamp
RECEIVED
APR 27 2018
0EPTo 9F PLANNING
eoMMU�lIfiY pEVEI.(?F�MENT
For Office Use Only
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 EIT playette Street McIntire ❑Washington Square
Address of Property: l � 17G
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Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed
Please type or print clearly.Attach addilio-nal sheets, as necessary.
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Name of Applicant: `� ,qC Z L(�,�✓ ❑
caner[]Contract Tenant -]Other:
Signature. :-'-7C mot--- Date:
Tel. #: 7/ - ,�Fnail Address: (J
Certificate will .e ruuiled to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: `-
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