21 Washington Sq No - C of NA application - replace garage doors not visible Date Stamp
R E E l
M R 21 2019
Salem Hist0fiCal Commission DEPT. F P LA N N I N Gnn&E N�
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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 OWashington Square
Address of Property:
Name of Record Owner(s): V�V;t�.Q
Owner Mailing Address: I
Description of Work Proposed
Please type or print clearly.Attach additional sheets,as necessary.
c84obi r OWCU [Voice- 0A E /.S N O V1S 76tc F:r-0Yk'C Tge:
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Name of Applica t: jtt�� Owner❑Contracto Tenant❑Other:
Signature: Date: r
Tel. #: t E-m Address: 'fit c'l C'
Certificate will be mailed to the owner unless otherwise indica e:\
Certificate should be mailed to: Name
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Mailing address: C���L`�S �} -- City: Sta f 1-zi
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