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Salem Historical Commission � [AMU IT P EVE' Li 'P &
�OMMiJNITY DEVELOPMENT
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970
;978)619-5685 FAX 1978,Tao-oaoa
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 V Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: El Derby Street ❑Lafayette Street f//McIntire ❑Washington Square
Address of Property: 40 Eel-eiyIl
Name of Record Owner(s): &/rC_,kr/l C( A-Z4,*
Owner Mailing Address: ' ��'a/-Wq,I _
Descrintion of Work Proposed:
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i photos of e.xisting conditions, taken from all public ways.
nclude
Name of Applicant: ❑Owner 19 ontractor ❑Tenant ❑Other:
Tel.#. J)-9 7 E-mail Address: ��oae �/ ,��/• �o"�i
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name �
Mailing address: `- City:&Vj#1 State: Zip: ��
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