101-103 Federal Street application l!KUr,�'�I
Salem Historical 1.oYl missioll
120 WASHINGTON STREET,SALEM M.ASSACHUSETTS 01970 For Office Use Only
(978)619-5585 FAX t9785 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 f7l Reconstruction Alteration
Demolition Painting F Sign Other
District: []Derby Street []Lafayette Street f4Mclntire Washington Square
Address of Property: A)5 rout.41, 'r 1
Name of Record Owner(s): _J,1J/'7j6S (9-Vl/ri
Owner Mailing Address: L0 3 EJCd 1,K1, ') -
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
f'rel4cf Tl
Name of Applicant: J �a�S /(,i, `.W/Td �wner[]ContractorE]TenantE]0ther:
Signature:I Date: - 2 2oY
Tel. #: (/ � _rZy L(o�� E-mail Address: A0 4 I iti,[, •��
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name -919MA5 (LW l U
Majlina_address: f U3 � � •l�L sT City: ;S4 ycivr State:,*7,jZip: 04!�_1