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180 Federal St - C of NA application - repaint Date Stamp Salem Historical Commission 120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970 For Office Use Only i978)619-5885 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 0 Painting ❑ Sign ❑ Other District: ❑Derby Street ❑Lafayette Street ©McIntire ❑Washington Square Address of Property: L$O F7 b ER 4-L. �� S�9 t`i 19 0 l 4 7d Name of Record Owner(s): 6 C K A" s ,QN�a��A G.aSPA`W_D Owner Mailing Address: S�9 Ham' A 5 AF�vt1F'� Description of Work Proposed Please tfPe orprint clearly: Attach additional sheets, as necessary: �. acv�`�� K �"� @N��✓� kousl� a 1A� Coors. lace � ,�f Q s ✓u e..e Name of Applicant: l�1 e HA lets SIV!Srtla2. CROwner❑Contractoro Tenant❑Other: Signature: � Date: Tel. #: lrq zs) 3 z q-- 4 Z 215 E-mail Address: E2tek s�?5 A R SBe 6 e o Bel t.NFT Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name Mailing address: City: State:_Zip: