330 Essex Stree unit 2 CofNA Date Stamp
Salem Historical Conanission
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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 Qy' Painting ❑ Sign ❑ Other
District: ❑i>erby Street ❑Lafayette Street 2< lmire ❑Nkashington Square
Address of Property: "nor 0c) V "I� nn
Name of Record Owner (s) : " 6nr ml< � )Onc cA° t_ cnL �" \�t"UP _ (°7sIt r,
Owner Mailing Address : 7-�"I�C x c- Oi-yA 7)-1 `�-Akem 1 � A VCl l0
Description of Work Proposed
Please type orprint clearly . Attach additional sheets, as necessary.
CS CtiA i C^ l (� � ` ' �C l C� i " �1 I 1..�.n t-1 C' U
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Name of Applicant: Oe.\as-isf G �Ur1 26wnerElc1011tractor❑ Tenant❑ ')ther:
Signature : / 6 iA Date : �D G i
Tel. #: 9 -1 % . `T5 _ I 1 q lc E-mail Address :
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to : Name
Mailing address : City: State :_ Zip :