11 Andover St - C of NA application - 3-tab roof , & 7A .
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APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY kvEL�fJNtfjr
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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
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: El Derby Street El Lafayette Street 1*4cIntire ❑Washington Square
Address of Property: �� �� p, -
Name of Record Owner(s):
Owner Mailing Address: 0/1/-7 )
Description of Work Proposed:
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Name of Applicant: re 4'r -rA 4SD r� )(Owner ❑Contractor ❑Tenant ❑Other
Tel. #: 4/7- 2.'5 5 _ 702 E-mail Address: 057-b v &1VI 7 S-6)Y/1#Q9 Cot-1
Certificate will he mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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