35 Broad St C of NA paint . fl
MAY 292018
EPT. OF PLANNING &
CO AMUNITY DEVELOPMEN
ent C 0 111111 S S - 1-
For Office Use On1v
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:
Q New Construction � Moving 0 Reconstruction Q Alteration
Demolition Painting MSign Other
District: Derby Street Lafayette Street dMelritire []Washington Square
Address of Property:
Name of Record Owner(s): AC-S -r I L r le i C C�
Owner Mailing Address: 6- vi'" S-r
Deseriotion of Work Proposed
Please t;pe or print clearly.Attach addilior d sheets,as necessan:
t� vo t, 1A GN C C' Ll t tq G y C-!i ) ✓ I
13 AA VVti A(,I t VA q 15 S<- — Ify� ►')sl
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Name of Applicant: tC% J ^ _ mow-ner[DContractor[]Tenant[ O er:
Signature: - Date:
Tel. #: -7 —_E-mail Address:ihr < Lt Ca G1 (c ' .� t`� c •�.c v
Certificate will be+nailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address:.W City: State:_Zip: _