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21 washington Sq - C of A application - snow fence Date Stamp Salem Historical Commission 124 WAS14INGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only (978)619-5685 FAX(978)74"404 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 [Z Reconstruction ❑ Alteration Demolition ❑ Painting ❑ Sign Other District: RDerby Street OLafayette Street McIntire NNashington Square Address of Property: _ �J-�x�,� -- Name of Record Owner(s): �uws LL-C Owner Mailing Address: // Descri tion of Work Proposed Please tree or print clearly. Attach additional sheets, as necessary. C,6M rOS)j(-C_ O/L-� ©dOiZ3 61jf.-1t-Z-C /_S Al L9 0516E fi�C `UC_ 91STVC-Ac DISM GT- ,2,) V::O"CE� t/,� _,_ _L _2fL `Dt— o�G Awl�,� Or— MI C i t r J� 1'`� 1✓` �l� -f, ,LLf C,i c_�� Name of Applied t: 1/'t� l' OwnerQContracto Tenant❑Other: Signature: Date: -5 Z� l 0 Tel. #: E-ma' Address: GL� 'Sps'°�-i�GG�GJ�t� C Certificate will be mailed to the owner unless otherwise indica re: Certificate should be mailed.to: Name VL C rs Q Mailing address: City: Stat J Zip: (2 aa�aap 4 i 3 c •� � a O N �• �� f I�III�IIAII - O °i CD ul - r N WASHINGT©N S(� m c E r.{ ��1��■�� e � saw��1`®a�o...�l��ro _ cnooac's,��2 —� q�3T`gym Q �'nQ3�.mm r SS�SSSS � 4 mrQ�✓q � � Pr Ty5'i w a m o Z w c �^ �z a�• t s x a e j §r. P. ny. r. 4 r i t' F : . q a la q t i a 4' �' ff F j�➢ Sir� / ��. :€