268 Lafayette St - C of NA application - 3-tab shingles i
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.IUL 17 2017
Salem Histofical Commission DEPT. OF PLANNING &
„OMMUNITY DEVELOPMENT
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970
,978)619-5685 FAX 1975)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 ❑McIntire ❑Washington Square
Address of Property: a,6 (--a - T e S�
Name of Record Owner(s): InCLHA'r, Rt'Qwj _
Owner Mailing Address:
Description of Work Proposed:
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Applications must include photos of existing conditions, taken from all public wayjs
Name of Applicant: ben m k L; ❑Owner Wontractor ❑Tenant l❑Other:
Tel. #: 944 -9r)51 E-mail Address: fnnr, s(a 7 rh�,,�f
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Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: __ City: State:_Zip: