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Salem Historical Commission
120 WASHINGTON STREET,SALEM.MASSACHUSETTS 01970
'978)619-5685 FAX f978 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 >(-afayette Street ❑McIntire ❑Washington Square
Address of Property: - L-A -
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed:
"0 V\L) Af�M
Applications must include photos of existing conditions, taken from all public ways
Name of Applicant:k6 g&►n,e_ Owner []Contractor []Tenant ❑Other:
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Tel. #: 113�-91.j - 6-, E-mail Address: G?tMCD 1q�5 Cow\
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: