3 River Street Rim 1 Yd L Salem Historical Commission
120 WASHrNGTC� STREET PL M r<q cq HUScTT. _ ..,, DEPT. OF PI.AN N ING &
.978,'619-568 Hf s°e .!-WC- I COMPAUNiTYDEVELOPMENT��b�
APPLICATION FOR A CERTIFICATE OF NON-APPLICABILITY t
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: El Derby Street Lafayette Street \McIntire ❑Washington Square
Address of Property: IZOU 'SI'C .'E'( . 5ca(cf-( r—I
Name of Record Owner(s): C 4 C({ U on n S
Owner Mailing Address:
Description of Work Proposed:
L70
Qelc� Ch; M�� C-,
• • conditions.
Name of Applicant: GAO" []Owner Contractor OTenant ❑Other:
Tel. #: 6 0 '3 - 9-SI 1 S7 c� E-mail Address: ICI a.( k.'d(�'i 4r1Gt.1•Cat i
Certificate will be mailed to the owner unless oth��gqvise indicated here: /1
Certificate should be mailed to: Name l SRe to L L
Mailing address: City: Stater Zip: 1 ,U
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