6 Sout Pine St - C of NA application - paint inkind Date Stamp
For Office Use On1v
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:
❑ ❑ Moving Reconstruction ❑ Alteration
New Construction ❑ ❑ Other
❑ Demolition 'I Painting ❑ Sign
District: ❑Derby Street
❑Lafayette Street tgMclntire []Washington Square
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Address of Property: 11 �,,� .r 1 Eck fo I ,,� o Y,�.
Name of Record Owner(s): (i rl I V w
Owner Mailing Address:
Description of Work Proposed
Please type or print clearly.Attach ad& onal sheets, as necessary.
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Name of Applicant: ftfowner[]ContractoUTenantr-L-"ther:
Dater 20�
Signature. �—
3 d E-mail Address: MPMKA 1A YUJI&
Tel. #:
Certificate will be mailed to the owner unless otherwise indic d her - ,(,t v
Certificate should be mailed to: Name '{/t, M'A
Sb PC �• City; A Wi Stag, Zip;
Mailing address: ��