335 Essex Street CofNA application Date Stamp
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Salem Historical Commission COM UNITY DEVELOPMENT
120 WASHINGTON STREET,SALEM.MASSACHUSETTS01970 For Office Use Only
i078)619-5685 FAX 1978)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 d Reconstruction Alteration
Demolition Painting Sign Other
District: Derby Street []Lafayette Street Da'c'Intire Washington Square
Address of Property: 3 3 5- ES 5e x -�4- /'bJ� e�
Name of Record Owner(s): Re, 6.nrl e2A e A.*, c� 144a %er—
Owner Mailing Address: 5 4tt.2—
Description of Work Proposed
Please type or print clearly.Attest add Mvial.sheets, as ttecessaq:
Ra-b `� ' �(k � ds�s �ettice Sec -�► CLL
New �JoS`j -k 4e- itK e Lon cr---1�e- e5LA,,-(
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Name ofApplipaft, ISO 6.t� e� 2pwnerOContracto Tenant[]Other:
Signature: < Date: 9� /T ?e t (o
Tel. #: R-7 69 7 — 0 r] l E-mail Address: 1'o bot- tM��e-�G�lauL�t A
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name �i<�61nP
Mailing address: City: State:_Zip:
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