8 Lynn Street - C of NA application for roof Date Stamp
Salem Historical Commission
120 WASHINGTON STREET, SALEM , MASSACHUSETTS 01970 For Office Use Only
(978) 619 5685 FAX (978) 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 ❑ Other
District : ❑Derby Street ❑Lafayette Street ZMclntire ❑ Washington Square
Address of Property :
Name of Record Owner (s) : l� N ��/ �t 10
Owner Mailing Address :
Description of Work Proposed
Please type orprint clearly: Attach additional sheets, as ilecessmy.
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Name of Applicant: ❑Owner ❑Contractor❑ Tenant []Other,
S ignature : Date :
Tel . # : &mail Address :
Certificate will be mailed to the owner unless othenvise indicated here:
Certificate should be mailed to : Name
Mailing address : City: State :_ Zip :