293 Lafayette Street Cof NA application Date Stamp
(\ :Y4/l
Salem Hi.sforit tit ( t,/ruraiy���irr�t
[For Office Use Only
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:
Name of Record Owner (s):
Owner Mailing Address: �EtT✓ o�P /ze a�f70
Description of Work Proposed
Please type orprint�clear/i/c AttacL adrli6i na/sheets, as necess'atr.
rX
W/Jh 7v µ��F/��/Jv✓I� ,��F JJ / SB/YP Cir�j r-/roT ,Q���
���� ,Qso? i1i✓� F'��is.? u/!r/� Gv/�✓A�n�l %�.'// .�?�un//� � �✓�6/i-✓/�
� r 'i1P jw/r
Name of Applicant: / r �T_ Owner❑Contractot❑Tenant❑Other:
Date:
Signature:_
Gt7 E-mail Address: 3
Tel. #: S4�' �l�
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address:
City: State:_Zip: