335 Essex Street CofNA application - roof and chimney Date Stamp
Salem Historical Commission
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970 GpNI.i Foc Office USCORIWT
(978)619-5685 FAX(97a)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 E]*' Reconstruction ❑ Alteration
Demolition 0 Painting Sign Other
District: Derby Street QLafayette Street 24clntire Washington Square
Address of Property: 33 , E S S-e X sf
Name of Record Owner(s): -P�-
Owner Mailing Address: et I c 6 0 ye—
Description of Work Proposed
Please ti pe or print cleeadv.Attach additional sheet., as necessary.
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Name of Appli4mt: /e , t,;e- E](I'wnerE]Contracto TenantE]Otber:
Signature: ��/j/e��.,.1� G- ��. Date: do LS' / 1
Tel. #: �j�����'7 D`7�/ E-mail Address: C-06e — 6L(a�tzi / �rs7,,iF¢
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Certificate will be marled to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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