10 Chestnut St - C of NA application - repair portico and repaint inkind Date Stamp
JUN 6 2019
Salem Historical Commission COD r PT.
OF �A�;'rJ�,(�r�G &
JiE7" For Office USe U�Ii�T
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 ;RMclntire []Washington Square
Address of Property: a r-A v �Nl D
Name of Record Owner(s): 1 vl if'rr (0 11S O U'f"r `�c -e:::�`dl r '-P o1►-�.-
Owner Mailing Address: 0 C -P , +.-r
Descriution of Work Proposed
Please type or print clearly.Attach additional sheets, as necesswy.
f �
/71 (A 6111),
V-/o c
Name of Applicant- P / Awner[]Contractor[]Tenant QOther:
Signature: Date::
Tel. #: 7 ' E-mail Address:11110 ffz V
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: