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J 08 2016
DEPT. OF PLANNING &
Salem Historical Commission COMMUNITY DEVELOPMENT
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 01970
(978)619-5685 FAX(978)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 ❑ Reconstruction ❑ Alteration
❑ Demolition Q-' Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street
� Kvlclntire ❑Washington Square
Address of Property: l.`l/ FC`jrZs,/ Cal-,
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed:
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Name of Applicant: 210 ALNEY 16wner []Contractor ❑Tenant ❑Other:
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Tel. #: 97R-74,5- LE E-mail Address: cts�A.ISI ���141� C{1u�
Certificate will he mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name Mailing address: SCLA-Ilff—GQ t-6d (ICL City: State:_Zip: