88 1-2 - 90 Federal Street - C of NA - priming f
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a lem HistoricalCommission c°M"UN TYo�VtLp
1201WASH?NGTON STREET.SALEM,MASSA HUSEiTS 01,970
{978)619-5685 FAX 1978?740-040
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 Ik Painting ❑ Sign ❑ Other
District: ❑Derby Street []Lafayette Street ` Vclntire El Washington Square
Address of Property: �j ]�� ` %) -F IAe. 1
Name of Record Owner(s): )r U
Owner Mailing Address:
Description of Work Proposed:
tr\rAQ
include-VC(�V\� DD)OTS
Applications must
. . conditions, taken from all public
Name of Applicant: LZO VTr 2 n--6, Owner ❑Contractor ❑Tenant ❑Other:
Tel. #:_C(IZ ^� � — 113 0 E-mail Address: Le 0,K ) Y4
Certificate will he mailed to the owner unless otherwise indicated r :
Certificate should be mailed to: Name 1 <V—q x n4
Mailing address: Q _ CitY7*_4_
Stateip: �
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