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Salem Historical Commission
-- 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:
New Construction Moving M Reconstruction Alteration
Demolition Painting 17Sign Other
District: Derby Street Lafayette Street 19MclntireElWashington Square
Address of Property: S+►j Lt S"t
Name of Record Owner (s): II eS 1 14 1G �t k Our1)
Owner Mailing Address: 3-7 G k h kf $(—
Description of Work Proposed
Please type of-print clearly.Attach additional sheets, as necessx y.
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Name of Applicant: �)A t CA RA V4,A a'1 j nownerE:]ContractoioTenant❑Other:
Signature: I Date: l 1-7 11
Tel. 4: E-mail Address: cl ►ra h A A ll 17-3 G k VfW 41 � ' ef"A
Certificate will be mailed to the owner unless otherwise indi d here:
Certificate should be mailed to: Name— PA %A 4,4
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Mailing address: 37 G� eS+k,,,►t S-r City: 54 tt4AA, State: Zip: