105 Federal Street Cof NA application house paint — 9 Date Stamp
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Salem Historical Commission
120 WASHINGTON STFEET,SALEM.MASSACHUSEITS O1970 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: QDerby Street ❑Lafayette Street McIntire QWashington Square
Address of Property: I Q S -f=e—A o rc`A SA—
Name V`- / 1
Name of Record Owner(s): 1 1 /l�-Q-N � P V�, V Get 1 v l<
Owner Mailing Address: O S a n �—
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
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Name of Applicant: pwnerOContractotOTenantQOther:
Signature: Date: /1,Z�f L
Tel. #: �' ` Z 9 —�o'� Z Z E-mail Address: k l+V cj, Cr tyl Cc- i c O z
Certificate 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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