6 South Pine St - C of NA application - new window openings ♦-tit .. �.._
Salem Historical Commission
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 ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property:
Name of Record Owner(s):
Owner Mailing Address: (r S°t4tf,% P) e G S A f e.
Description of Work Proposed
Please tlpe ol-prrnl clearly.Attach addrd'onal sheets, as necessary.
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Name of Applicant:' lr LA S []owner[]Contractor[]Tenant ather: n-i.7e4,-e
Signature:I Date:
Tel. #: 7 0- 1_ S Y, E-mail Address: kc-le,to (f �je. I L4 S
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State: Zits:
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