Application for inkind painting - 17 Warren Street r
X RECEIVED
Salem Historical Commission SEP 2 9 2016
120WASHINGTONSTREET SALEM.MAssACHUSE-17S01,970 DEPT. OF PLANNING &
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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 []Washington Square
Address of Property:
Name of Record Owner(s): b erm l A - �:rC._LSrTrl
Owner Mailing Address: + _ �JA `�r-1 1rr'• S L_fEl_
Description of Work Proposed:
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Applications must include photos of existing conditions, taken from all pub(ic:=ways_
Name of Applicant: Owner �❑Contractor ❑Tenant []Other:
Tel. E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name �z �� - J —
Mailing address: 1 City: S4 Statel*ip: