5-7 Chestnut St - Cof NA application RECEIVED
' M 10 2016
DFPT, OF PLANNING &
Salem Historical Commission COMMUNITY DEVELOPMENT
120 WASHINGTON STREET.SALEM.MASSACHUSETTS 0!9M
j978)619-5665 FAX(9781740-0404
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 ❑Washington Square
� S71
Address of Property: 5-7 4sjmol—
Name of Record Owner(s): �t w \:gPar-
Owner Mailing Address: .S rVi-e,S);'+a'J— S 4
Description of Work Proposed:
• • 01 1 zzsmc • •)1 Ell KII.M03its • • • •
Name of Applicant: La4r& Owner ontractor []Tenant ❑Other:
Tel. #: / 31`/ 6 -7 jQ E-mail Address: j?hd4jf(0,*4cS01,e0tr
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: