24 Hathorne Street Cof NA application Salem Historical Commission,ONIMUN I 1--F,1
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120 WASHNGTCN STREET SALEM.MASSACHUSETTS W97C
i978j 619-56&5 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 e Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: []Derby Street ❑Lafayette Street McIntire ❑Washington Square
Address of Property: „ Nafharn, 3 f•
Name of Record Owner(s): J / G1C Do rwi lA
Owner Mailing Address: A./ 11A1Xo rn c . + .
Description of Work Proposed:
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Name of Applicant: S'-� Pi erg ,D iVc(_ ❑Owner contractor ❑Tenant ❑Other:
Tel. #: :2P/-6i2- E-mail Address: . 5 "FN e' 544V&u cow-,
Certificate will be mailed to the owner unless otherwise iccdhere��'�Lr
Certificate should be mailed to: Name ��
Mailing address: �� /76/1I / Y4 _ City:S41,e& State/44 Zip: d 14