Application for Cof NA - 47 Washington Sq ; RECEIVED
NOV 03 2016
Salem. Historical Commission
DEPT. OF PLANNING&
120 WASHINGTON STREET.SALEM.MASSACHUS=rrS 01970 COMMUNITY DEVELOPMENT
978j 619-5685 FAX i978!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 ❑ Painting ❑ Sign ;Washington
Other
District: ❑Derby Street []Lafayette Street [-]McIntire Square
Address of Property: -7 uJ Cu -
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed:
� P
Applications must include photos of existing conditions, taken from all public ways']
Name of Applicant:le,_%t--- -e. 11—L 0 ❑Owner JC;-6ntractor ❑Tenan ❑Other:
Tel. E-mail Address: v
Certificate will be mailed to the owner unless of erwise 'i is ed h re.'
Certificate should be mailed to: Nam
Mailing address: City: Stater