DOC051616 Date Stamp
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Salem Historical al Commission
120 WASHINGTON STREET,SALEM,MASSACHUSf TTS 01970 For Office Use Only
(978)619.6685 FAX(978)7,10.0404
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 L/� Reconstruction Alteration
Demolition � Painting Sign0 Other
District: Derby Street Lafayette Street QMcIntire Washington Square
Address of Property:
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed
Plcase lipe oi-jn:rIit cle.ail; Amacb addition it slleels as rlccess�vy.
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Name ofAppl' nt
Signature Owner[�Contract rQT nantQOther:
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Date: 3 /
Tel. #:��� -�7�1� %_7 E-mail Address:
CT i t ate will b!nI led he owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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