2-4 Beckford St - C of NA application Date Stamp
Salem Historical Commission
120 WASHINGTON STREET.SALEM MASSACHUSETTS 01970 For Office Use Only
(978)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 2Nlclntire ❑Washington Square
Address of Property: H e Lk A�-d_ (o �f
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Name of Record Owner(s),: J. �� s++rt n14 (cy
Owner Mailing Address:
Description of Work Proposed
Please ope or print clearly.Attach additional sheets, as necessary.
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Name of Applicant: Rt-y\ IVLL4&.- N6/wner❑Contractoi❑Tenant❑Other:
Signature: Date: 3bob
Tel. #: - ;-{ E-mail Address: T PjL,2LrY\-CJQ-xAC fir, -C v rh
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip: