26 Chestnut Street Cof NA application Date Stamp
V pp tz�
r
Salem Historical Commission °O
- - - - - 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 Fj Reconstruction Alteration
❑ Demolition ❑ Painting ❑ Sign � Other
District: QDerby Street QLafayette Street PDMclntire Washington Square
Address of Property: v 7
Name of Record Owner(s):
Owner Mailing Address: H C(11�.42 ��Ll
Description of Work Proposed
Please type or print clearly.Attach additional sheets,as necessary.
ltiST4tc 4,L-- U.41 < OAJ Cc4i-14Auj
U2sus � �4bk z�oy E7�!�T
jG�/(/r l'0 S7v4 try -`0
LCJc)t� , 7s o#,J 74 Onz
Name of Applicant: 1"S!'311�j �o ��OwnerOContracto TenantQOther:
Signature: Date:
Tel. #: �- S�7 S �� E-mail Address: �,�ity{� o��
L
cate will be mailed to the owner unless otherwise indicated here:
ficate should be mailed to: Name
ng address: o City: State:_Zip:
lw
4
I
S"
� "' .
1