347 Essex Street - application for vent pipe RECeIVILD
<<�( = NOV 18 2016
DE IT. OF PLANNING &
COMO,UNITY DEVELOPMENT
Salent Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHJSETTS Cis:c For Office Use Only
r978 619.563.5 FAX 19781 740-0434 .
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 ofNon-Applicability as described below for:
❑ New Construction ❑ Moving ❑ Reconstruction PO'Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street Entire ❑V1,'ashington Square
Address of Property:
Name of Record Owner(s): Cr✓
Owner Mailing Address:
Description of Work Proposed
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Name ofApplican wner❑Contractor❑Tenant❑Other:
Signature: )l 'Cvee w ow,, • Date: 'V IE 10/1C
Tel.#: v� E-mail Addres : A Opev9,
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Certrcate will be mailed to the owner unless otherwise indt d here:
Certificate should be mailed to: Name_ _ .. •
Mailing address:_ _ City: State:_Zip: