0 North Pine St - C of NA application - 3 tab roof (002) 7.44
Date Stamp
s
a DEC 4 9 2019
DE 'T. OF PLANNING Y�
Salem Historical Commission COMM JNITY DEVELOPMENT
For Office Use Only
,Y 0
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 0 Moving ❑ Reconstruction ® Alteration
Demolition Painting Sign Other
District: Derby Street Lafayette Street "McIntire Washington Square
Address of Property: .P)NE S-r 5A LE M . M A Q 19 7 b
Name of Record Owner(s): -DA N 4- JA M i f GRAHAM
Owner Mailing Address: 5 A M E A 5 A R OVE
Description of Work Proposed
Please type orpli111 cical-lj:Atlacl)additionalslleets, as_lecessaly.
WE TALL (,; P\EPLACIty G )�k15 r IIVG "T/lb &ZAc_�c Roar
WITH A NEV 3 -TAG BACK R60F.
Name of Applicant: _D4N t JAMIC- 6014 A M_ ZOwner[:]ContractorQ Tenant QOther:
Signature: t Date: l /5/)l
Tel. #: '"7 .5 7 'd'? E-mail Address: AjV- 'rH F. G AAH 4 M @ G M11L,�orvt
_LLCertificate will be moiled to the owner unless otherit ise indicated here.-
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: