1 Lynn St - Certificate of Non-Applicability application - repointing Date Stamp
Salem Historical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619-5685 FAX(978)740-0404
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 ❑ Sign "a Other
District: ❑Derby Street []Lafayette Street >PcIntire ❑Washington Square
Address of Property: LvnA
Name of Record Owner(s):
Owner Mailing Address: �Naa '�C
Description of Work Proposed
I'lease type or print clearly. Allach additional sheets, as 11eressary
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Name of Applicant: e �l^ Im-tA� ` wner❑Contractot❑Tenaant ther:
Signature: t1001
Date: y 4e� `�
Tel. #: s 67 E-mail Address: 1 ` /t
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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