4 Andover St - C of NA application - rebuild chimneys 9!
RECEIVED
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Salem Histotica (�mmission DEPT. OF PLAPiNING &
120 WASHINGTON STREET.SALEt 5.MASSACHUSETTS G t 9M COMMUNITY DEVELOPMENT
tQ7 u =AX(g78)740-0404
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 41ntire
❑ Other
District: ❑Derby Street []Lafayette Street ❑Washington Square
Address of Property: 4 y,,, �`1 G m
Name of Record Owner(s): Sty Y1 ✓1 �U f ,r ' y 1 a
Owner Mailing Address: ��G0 ,M
Description of Work Proposed:
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Applications -
Name of Applicant: V V1 ®' �U4� Vwner ❑Contractor []Tenant ❑Other-
Tel. #: 17 tl'( 05, E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated re: 1L
Certificate should be mailed to: Named U ►`f� T_�YL
Mailing address: A ' ie, - SOT City:5a WM State"Zip: 6 �70