14 Chestnut ST - C of NA - inkind painting V CLLIi U LUlll�l
Salem Hist orwal. Commission 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 C Moving C Reconstruction = Alteration
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Paintin l- Sign gn Other
District: CDerby Street iD Lafayette Street tire —Washington Square
Address of Property:
Name of Record Owner(s): l { R t4S
Owner Mailing Address: j a *lx
Description of Work Proposed
Please type or print clearly. Attach additional sheets, as necessary.
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,,T"Contractor �
Name of Applicant: ���� Owner ,�� Tenant] Other:
Signature: Date: [�
Tel. #: — �� �' f 7 / 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