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�-° DEPT. OF PLANNING &
Salem Historical o� + issio COMMUNITY DEVELOPMENT
120101ASHINGTON STREET.SALEM.MASSACHUSETTS 0S970
,978)619-5685 FAX{978�740-4u04
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: El Derby Street El Lafayette Street X 4clntire El Washington Square
Address of Property:
Name of Record Owner(s): C(Pr 'r^]l S-�ra vg ¢ -� G �n-P g-P rrjjr►-P
Owner Mailing Address: /0 C ,P,-I� rr
Description of Work Proposed:
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Applications must include photos of existing conditions, taken from all public ways.
Name of Applicant: l " aPr)o lI r'Aw of S ,Owner ❑Contractor []Tenant ❑Other•
Tel. #: 67`7j�2 S 51r S' ®t —,7 E-mail Address: / '/C��r'l u//�S�-A US s' kr,/V r'o-4�
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: