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126 WASHINGTON STREETSALEK MA CHUBE TTS10 70 For Office Use Only
APPLICATION FORA E C RTIFICATE OF APPROPRIATENESS
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 Appropriateness ro riateness for:
❑ Moving New ConstructionFReconstruction Alteration
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Demolition Painting C] Sign ❑ Other
District: ❑Derby Street Elafayette Street ENcintire ❑Washington Sq uare
Address of Property. ,
Name of Record Owner(s).- C,Y
Owner Mailing Address:
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Description of Work Proposed
Please type or print clearly.Amwch additional sheets, as necessary.
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e of Applicant: [ZOwnerFContractor Tenant Other:
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Certificate will be mailed to the owner unless otherwise indicated here:�I= Certificate should be mailed to: Name j'0Y
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Mailing address: city*. State: Zi
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ATTACHED DOCUMENTATION
An application will not be considered complete unless all work items are thoroughly described and the application
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includes all information needed or the Commission to make a determination.
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Failure to submit a complete gpplication may result in a continuation to a.future meetin .
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Recommended information includes:
Photos of existing conditions, taken from all public ways
Site plan showing location of improvements
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— Elevation drawings,of the existingconditions and proposed improvements
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Drawings of details and other special ' ' 'gconditions, including profiles
Description, photographs, and/or catalog cuts of proposed materials (please brin to the
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meeting product samples, if appropriate)
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-- Dimensions (i.e. height of fence, size of pickets and posts, etc.
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Paint color samples, if applicable (no less than 2"x2"
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---- Location and size of all mechanical equipment, such as transformers, HVAC equipment,
electrical service andmeters, and proposed screening
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