23 Chestnut Non-Applicability Applic (Edwards) Date Stamp
_Sa
Salem Historical Commission
120 WASHINGTON STREET SALEM MASSACHUSETTS 01970 For Office Use Only
(9781 619 5685 FAX 1978)740.Od0a
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 LA
Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑I.aiayette Street r\iMclntire []Washington Square
Address of Property: CH(irk J t' S T k L)T S kI.0-M , IAA 0 t C nQTi
Name of Record Owner(s):
Owner Mailing Address: a 3 C kE( S,LEAA ) NSA 0101�k
Description of Work Proposed
RazeWor print daw'ly AtW7 aaUitionaf&iets asnaximay
(tilLl L61 7n d�en�vtr 7trr o .Si1�I�2 DES IN TkC fl-e--Ak &C pqC fil6%4Sc/ L)"C
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(JmMe Abju li\i b 7NE, W W i'00 k6, W�
uJt1 t S 11�;b LG �`I V�Ca�C w
Name of App icant: A^. o n S � Owner❑C'ontractor❑Tenant❑Other:
Signature:
Date: lZ
Tel. #: f ' �S ( ' L-q 3 E-mail Address: � �P N1) �f N M
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: