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180 Federal Street Cof NA application
Date Stamp Salem Historical Commission .29%?VA.S rfticroN sTREEr,SAL_cM neassaC�reSSTTs e1 s?n 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 Fj Moving Reconstruction © Alteration Demolition Painting Sign ❑ Other District: ❑Derby Street FIl.ata}cue Street tclntire ❑w'ashington Square Address of Property: / �d F7-e-cPe rc-( An Name of Record Owner(s): �(zk qV 0 A hit' AK4-o K I o", 67a5 r q ✓4 Owner Mailing Address: /ffo s;+, O(r/7O Description of Work Proposed Please type or print clearly. Attach additional sheets, as necessary. �cpcca/ or }�e/a �ocenser. a 1pct"tcJtdbc,T, I e onyoeK�_refiS a-C S I'd k�l 4uuG1vi7s StisT�tt weal v�a ww� e �Qc.�e -f-d tve�-I-e r of/ _vf� �I O V Iwto�1 vtl e ow aL" -f-vaeV' t-o i 4 �1.1 a�e V t c�l S f Y1 7�i K4 Gi'no9 �cctv�"�` f�ec1"f-�eaP -f-o �kr^rev��. NameofApplicant: /'2_tcAeyd 65^ 6ra$)oAr E�(IwnerE]ContractotflTenantE3Other: Signature: ,, !!� - Date: ' sa r p p Tel. #: �o'Zal -3;Z 'T- -72; � / E-mail Address: /-f CA�e/Lf S Pq✓J425 Certificate will be mailed to the owner unless otherwise indicated here: Certificate should be mailed to: Name Mailing address: City: State:_Zip: