293 Lafayette Street - C of NA application Date Stamp
_.7
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 n Sign ❑ Other
District: Derby Street Lafayette Street []McIntire []Washington Square
Address of Property: �r i �e '
Name of Record Owner(s): "r�Z X 11 caii-aV
Owner Mailing Address: _7_7 Zee cl 1 1,/1?_!P S 1661 /" d427C)
Desmntion of Work Provosed
/ Please ope or print clearly.Attach additional.sheets, as necessary.
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Name of Applicant: k' CL c�0i MlOwnerOContractoroTenantQOther:
Signature: Dante: 6 '
Tel. #: �c d% /`�tf:7 ��du E-mail Address: #l1c'GPI,)r4
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name r`nkL �✓c�'����
Miiting address: 33 144;erl Xllllf P City: Stater Zip: O/f7U
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