126 Derby St - C of NA application roof Date stamp
For Office Use On y
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:
tion Moving Reconstruction ❑ Iteration
❑ New Construe ❑ g ❑
Demolition ❑ Painting ❑ Sign Other
District: erby Street ❑Lafayette Street ❑McIntire []Washington Squie
Address of Property:
Name of Record Owner(s): ^c-Z
Owner Mailing Address: a ' Z t
Description of Work Proposed
Please tvpe or print clearly. Attach additional sheets, as Decessary.
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