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31 Washington Sq No - C of NA widows walk f ',' V �. RECE ItiAY 2 2 2017 i Salem Historical Commission o DEPT. OF P!_'ANININ# 1201WASHI INGTONSTREETSA EM.MASSACHUSE 1s01970 COMMUNITY DEVELOPMENT 978j 619-56685 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 ❑ Other District: ❑Derby Street ❑Lafayette Street []McIntire ngton Square Address of Property: L� rA / �0"tA L1 . Name of Record Owner(s): Owner Mailing Address: Description of Work/proposed: ` c 6e"� �r�1 � jApplications must include photos of existing conditions, taken from all public ��,/ Name of Applicant: ta CA- �-- I�wner ©.actor ❑Tenant ❑Other: Tel. #: �� E-mail Address: Certificate will be mailed to the owner unless otherwise in icate here• Certificate should be mailed to: Name �` X - Mailing address: t4, //i,>1 s ,7/0 City: �� r�i State UL22l--