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8 Broad St - C of NA application - garage i s / 7Z v I,( I .G llJ Z J v� vs _ rj Aj 4p ul ly Date Stamp 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: ❑ New Construction ❑ Moving ❑ Reconstruction Alteration ❑ Demolition ❑ Painting ❑ Sign ❑ Other District: ❑Derby Street ❑Lafayette Street ❑McIntire []Washington Square Address of Property: SS ✓'a d .+' Name of Record Owner(s): G k A v(C s , �a H v► ��,(� ►ticQ Owner Mailing Address: 8 8✓ e f" Description of Work Proposed Please Type orpniut clearly.Attach additional sheets, as necessary. � 1i'C>_� I � rp LI �tctS f (Ar UYS, " vw �' vlsit,� i Name of Applicant: Downer❑Contractor❑Tenant❑Other: Ayt. c t Signature:1. 1 Date: 3©( Tel. #: q Z 5 -3*✓I- !�'9 G E-mail Address: Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name �`+''°` �" � Mailing address: �'a �fi City:43G le w^ State ��`�Zip: