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Salem Historical Commission DEPT. OF PLANNI
NG &
120WASHiNGTON STREET.SALEM,MASSACHUSETS()1970 COMMUNITY DEVELOPMENT
(978)6 i 9-5665 =AX;9'S 3 740- Qv -
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 )J Other
District: El Derby Street ❑Lafayette Street )4Mclntire ❑Washington Square
Address of Property: I?— )�:j lA W y7 �Y _1 ;T
V Name of Record Owner(s): G c -r 2 e 14 e 1 Q r
Owner Mailing Address: -V(? G- ,� Q V 2 r' MA f? ]9/
Description of Work Proposed:
Qe� ) oic e T) �4,
3 -Tp•� � L,--�l e .
c-0�v A-S-X� -L.
to: z9A.nA 5 ,;i+-t In
Applications must include photos of existing conditions, taken from all pub�ic�ways.
Name of Applicant: L(A,� ❑Owner Contractor J❑Tenant El Other:
Tel. #: �� 7- �� 5 (Q E-mail Address: _r&1�7UJ l' 1 11 0
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: