123 Winter Street - Cof NA application - storm windows Date Stamp
Salem Historical ommission
t:':'1ASHIN.-ti^3 STR;-FT.SA'.FM ACHU'ter—;F-C.-M-i For Office Use Only
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.
® Reconstruction Alteration
New Construction Moving
Demolition Painting Sign Other
District: Derby StreetLafayette Street ®McIntire EjWashington Square
Address of Property: C 7'5 -F ejP or _, .ST ,e,
Name of Record Owner(s): kikeic 6 U hj�V1
Owner Mailing Address:
Description of Work Proposed
Please hyie orjuult cleadv.Attach aciclitiorlal sheets, as riecessaij
Re06ck
�JO A%Wv 1(A C-o JOVr 1 r"4e Irld I di s ir CaAm or- 9 w4vaA4
c rle c. . Non- 1i c�kb 4v be4 fki-C tvj
tzf ffla*4.
Name of Applicant:_MR14 � �iI�11�f L [OwnerOContractouoTenantE]Other:
`�`-�
Signature: _ Date: Ped•-6"I•- 17
Tel.#: E-mail Address: -
Certificate will be mailed to the owner unless otherwise indicated here:
i
Certificate should be mailed to: Name
Mailing address: City: State:—Zip: