3 Cambridge Street - C of NA application - inkind repair of gate DateStamp
Salem Historical Corr missivii 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:
C New Construction C Moving r Reconstruction C Alteration
C Demolition C Painting C Sign E Other
District: CDerby Street Lafayette Street Wrelfitire Washington Square
Address of Pro l
Property:
Name of Record Owner(s):
Owner Mailing Address: 0,vVI , Y 1
Description of Work Proposed
Please type or print clearly. Attach additional sheets, as necessary.
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Name of Applicant: Contractor Tenant] Other:
Signature: �j�� �, � -In Date:
Tel. #: 2 �L I�% � �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:
ATTACHED DOCUMENTATION