255-259 Lafayette St - C of NA application - inkind painting r Date Stamp
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Salem Historical Commission
Q0 WASHINGTON STREET SAI-EM.MASSACHUSETTS,! "•? For Office Use Only
.9781 619-5685 FAX ='?:'a0-040d
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 KLafayette Street []McIntire ❑Washingtton Square
Address of Property: o� � a c� r`�N `A( �_ 3-1 l OA 6'
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed e
Please type orprint clearly.Attach additional sheets, as necessary.
� � S
Name of Appl nt: �l �� �J _ O)wner❑Contractor❑Tenant❑Other:
Signature: Date:
Tel. #: E-mail Address:
Certificate will be mailed the o runless otherwise Sdicaled her �
Certificate should be mailed to: Name � C
Mailing address: �' � ��� City: State:_Zip: 06