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Saleir Historical Con-unissioll
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-.
Fj New Construction Moving R Reconstruction Alteration
Demolition Painting El Sign H Other
District: QDerby Street "Lafayette Street ( E3MCIntire Washington Square
Address of Property: is E-�
Name of Record Owner(s): + i L LAA
Owner Mailing Address: Z 6'_ y-V (iC
Description of Rork Proposed
Please type or print clearly.Attach additional sheets,as necessary.
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Name of Applicant: i
Pp �[�►�rier❑Contracto>❑Tenant❑Other:
Signature: Date.-
Tel. #:_ �� E-mail Address: 1 Q nM i; G
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: " CiV` f
ty: State:_Zip:
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