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pFPT. OF GL AN N':
COMMUNITY D -VELOFI""
Salem Historical Commispon
VO NASHiNC,7O^i starF'Gs .:�k; For Office Use Oniv
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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 ❑ Painting ❑ Sign Q- Other
District: ❑Derby street ❑/nLafayette Street ❑McIntire ❑Washington Square
Address of Property:
Name of Record Owner(s): t.7 ay/r Aaa 'r
Owner Mailing Address: )S U
Description of Work Proposed
Please type orprmtclearly.Attach additional sheets, as necessary:
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Name of Applicant: .Jan 11 ❑Owner j Conuactor❑Tenant❑Other:
Signature: i62%e er/r •,"v Date: till/�/6
Tel.#:✓' h A 3 - ly E-mail Address: �``1!r/tt6:•�/ropP�-yL7✓r.�zo� 4ir�
Cert*ate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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Professional Roo ing Co ' j--
James W. Shea, Presiders
P.O. BOX 262 45 DEARBORN ST
SALEM,MASSACHUSETTS of
PHONE(978) 744-6888 FAX(978) 7
profess ionalro ofing@verizon:
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