C of NA application for 3 Federal Court R E C E pvc
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CpDEFT. OF pi
M�UNITY DEVE LOPh�iEp;�-
Salem Historical Commission
120 WASHINGTON STgEET SALEM,MASSACHUSETTS 01970
1978)619-5685 FAX(978)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 ❑Washington Square
Address of Property: 3 Fedora k Loy- �Name of Record Owner(s): l t(iC aKd �fa r i-e OtI
S o v,)
Owner Mailing Address:
Description of Work Proposed:
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ns must include Dhotos of existing conditions. tzkc.-u
Name of Applicant: - Owner -Contractor Tenant 'Other:
Tel. #: ��7 7 �� - d E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name -r i I :-
Mailing address: City: State:_Zip:
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