39 Warren Street Cof NA application (002) Salem Historical Commission C
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3 For Office Use Only
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:
F1 New Construction Moving Fj Reconstruction Alteration
F] Demolition Painting Sign H Other
District: nDerby Street OLafayette Street []McIntire E]Washington Square
Address of Property: 3� W acre.,-, e-f S FN(� ky) A 0 15-1 G
Name of Record Owner(s): W I 11 i a-m (Y') (e c,(,I r -jr" •es
Owner Mailing Address: MrI
Description of Work Proposed
Please type orpnnt cleady.Attach additional sheets, as necessary.
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Name of Applicant: �er[]ContractorE]TenantE]Dther:
Signature: -U.������] Date: 4j,?c>/2ojC
Tel. #: E-mail Address:
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State: Zip: