11 Andover St - C of NA application - repaint inkind Date Stamp
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AR 2 9 2010
Salem :historical Commission
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120 WASHINGTON STREET,SALEM.MA8SACHUSETTS 019-0 CO M M I ,�-Fa vffikc(N�Clnly
(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 JR Painting ❑ Sign Other
District: Derby Street Lafayette Street McIntire Washington Square
Address of Property: l 04 n r/ ✓Q.,
Name of Record Owner(s): K.'c_I- ay ICea-, a es
Owner Mailing Address: ►i eld tee` S S u/� 01� 2,v
Deseriation of Work Proposed
Please type or prvit clearly.Attach additional sheets, as necessary.
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D to/$ u v� u .ice Mc)v/e Pa 'et �s
Name of Applicant: gowner[]ContractorF]TenantQOther:
Signature-,- Date:3Z`I!I 1
Tel. #: 617- z.33- -7 rl 2 , E-mail Address:
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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