Non applicabilty app_359 Essex_exterior paint Date Stamp
Salem Historical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619-%85 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 [Z Painting Sign ❑ Other
District: Derby Street Lafayette Street XVlclntire EjWashington Square
Address of Property: S '5-f W r
Name of Record Owner(s): Leo V Iry
Owner Mailing Address:
Description of Work Proposed
Please tr pc or print cleark.Attar/i;Iddltlollal.Shcets, as necessary.
c Re c-I CC�v I 1< Pr;� ,� �0,I-V\I f �e �eY�0U-- �11-11
c\
S
C ` q ti Lo� k4 \
Name of Applic nt: rxOwnerQContractorQTenantQOther:
Signature: // ,n, Date:
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: