40 Flint Street - C of NA application - Replace roof Date Stamp
Salem Historical Commission;
120 WASHNGTON S?REEs.SAiEEM.MASS'ACHUSETT S 01970 For Office Use Only
1978)619-5685 FAX;9 '110-040a
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 [�j Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street IWIntire ❑Washington Square
Address of Property: y2/ f __/; �
Naive of Record Owner(s): -1/J
Owner Mailing Address:
Description of Work Proposed
Please t t pe or pr u'k clearly,Amacli ad&i onal sheets; as necessary
Name of Ap nt: caner❑Contractor❑Tenant❑other:
i 1n
Signature Date: i
Tel. #: s 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:
ATTACHED DOCUMENTATION
An application will not be considered complete unless all work items are thoroughly described and the application
includes all information needed for the Commission to make a determination.
Failure to submit a complete application may result in a continuation to a future meeting
Recommended information includes:
Photos of existing conditions, taken from all public ways
Site plan showing location of improvements
Elevation drawings of the existing conditions and proposed improvements
Drawings of details and other special conditions, including profiles
Description,photographs, and/or catalog cuts of proposed materials (please bring to the
meeting product samples, if appropriate)
Dimensions (i.e. height of fence, size of pickets and posts, etc.)
Paint color samples, if applicable(no less than 2"x2")
Location and size of all mechanical equipment, such as transformers, HVAC equipment,
electrical service and meters, and proposed screening