384 Essex St Application for a Certificate of Non- Applicability pg 1 Date Stamp
Bolan Historical Commission
124 wASHNGTON STREET.SALEM,IIASSACHUSETTS 01870 For Office Use Only
978)319-5685 FAK(978)740-t3404
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 �clntire ❑Washington Square
Address of Property: `1
Name of Record Owner(s): � C -dve
Owner Mailing Address: l�' ^eeAf 'ter oeVAA44e �ea )
Descr!Rtion of Work Proposed
Plc�se 4y)e orprintclexiv.Attach 44(ftional.she tv, 2s nec.•cssxy.
IV •s�cE'�'lA �� �' 144ele
Name ofApplica :J�,LJsQ ORe AM zo-- ller❑Contractor❑Tenant❑Other:
Signature: Date: Z<1 , 7
Tel. #: 6�;� �lS �9J E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name