11 Andover St - C of NA application - replace window sills inkind Date Stamp
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Salem Historical Commission
120 4VASI IIP GTON S;RE &A M:MASS A CHUSA'I",S:J1 w7; 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 NMclntire ❑Washington Square
Address of Property:
Name of Record Owner(s): _R/e/,J I!0 K67N J3ReWf 7_h10/h IOX6 I
Owner Mailing Address: NDO V,f_'k S f C&4LE/IK IM 0/ 770
Description of Work Proposed
Please type o!-piirlt clearly.Attach ackhhonal sheels, as Ilecessaly
�/}I�yrE2s To 4E/4,4Ce .S�/h4 /f or-ri�6 �oaD �til�
411711 /N ,I(AV4 W o o A TiCIM
Name of Applicant: And mowner❑Contractor❑Tenant❑Other:
Signature: w.:.•�n� Date: St-�. —f
Tel. #:GI 4 C 99- q E-mail Address: tad Cony
Certificate will be mailed to the owner unless oth vise indicated here:
Certificate should be mailed to: Name1 cly4tD �
Mailing address: /I I71tld4V'rt Sr City: I Statet ip: ���