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Salem Historical Commission
120 WASNENGTON STREET ISALEM MASSACHUSMS0197!.
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APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY
�p C�� Pursuant to the Historic District's Act(M,G.L. Chapter 40C)and the Salem Historical Commission Ordinance,
O ' application is hereby made for issuance of a Certificate of Non-Applicability as described below f6r:
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[I New Construction 0 Moving Reconstruction e�ltenat:c.r.
Demolition Painting ❑ Sign other
District: ``;Derby Street ❑Lafayette Street Q4clntire Washington Square
Address of Property: 0_a a vrti1C C cS a--[ 2 L�
Name of Record Owner(s): 1 ►y l Ems.! 1 + s s�eA I
Owner Mailing Address: J CjAg- {P 4,,tiL.tr "!,
Description of Work Proposed:po.- aiAGrQ.4(v2 pR 1,iaoSe1 U- V� I,tVY1�r1lJVvl v �mS.
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Name of Applicant: lellnLa[CL 1,dwner Contractor : Tenant `Other•
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C'eruficara will he mailed to the owner unless otherwise indicated here-
,C'ertificaie should be mailed to: Name
ailing address: CiTy: Stater Zip:
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