366 Essex Street RECEIVED
FEB 2 2 2016
gEPT. OP PLANNING &
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Salem Historical Commission COMMUNITY DEVELOPMENT
120 WASHINGTON STREET SALEM.MASSACHUSETTS 01970
i.978j 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 ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: 346 6S S e It 5 t
Name of Record Owner(s) �1y
Owner Mailing Address: xcyy'e.. �ed�a6�1/ � tri176 a
Description of Work Proposed: 1
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Name of Applicant: Q C6 Va i � �: 1 []Owner Pl�_ontractor ❑Tenant ❑Other:
Tel. #: 6 (1 ?9r F 3 8's 7 E-mail Address: s P C,_ty%Le CotviC ass w e F
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: