Cof NA application - 112-114 Federal Street painting Date Stamp
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Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619.5685 FAX(978)740-0404
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: ❑Derby Street ❑Lafayette Street YMclntire ❑Washington Square
Address of Property: I I Z- I l y A L sT-
Name of Record Owner(s): Lo Iz( 1-+A rz-r * 5"rF- Z r PP i u -1 (I 1-2 : PA V L -ruTT L-E-- S K
Owner Mailing Address: It 2-- t I L4 4E_�L- s-} E
Description of Work Proposed
Please type or prrllt clearlf:Attach ad& oral sheets,as uecessar7
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Name of Applicant: )downer ❑Contractor ❑Tenant ❑Other:
Signature: Date: -►�I-I "1
Tel. #: b I -7 ?4`t - 8 6 4 cl E-mail Address: o w l Ga rvL a i I . co rvt
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: P. O. Bak S [j,9 City:SA L e-7,A State.YAAZip: o1110
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