39 Warren Street Cof NA application 4
31
Salem Historical Commission
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
H
Demolition Painting 7 Sign H Other
District: ❑Derby Street QL.afayette Street QMclntire ❑Washington Square
Address of Property: 3 c� W 0.-re r, SA-t Q e-+ , S A (�_� vn A c) 19-1 U
Name of Record Owner(s): VJ i 1 l i ck-m m. } (e c. Qcaye
Owner Mailing Address: 3 re e S A le.., 9 -U
Description of Work Proposed
Please type orpnnt clearly.Attach additional sheets, as necessary
Pa;hk coloC
Name of Applicant: I_f �er❑ContractotElTenant❑Dther:
Signature: Date: 4 10 12 o l b
Tel. #: `t 1 �—3t1—�� `I 3 E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State: Zip: