15 Chestnut Street - C of NA application - repair and repoint chimney Date Stamp
Salem Historical Commission
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12, '.'VA . ++N-ON s REE ,SA�Efvt AS;KH;:�aFr S. -^ For Office Use Only
(978)6'9,6685 FAX t978)..
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 0 Reconstruction ❑✓ Alteration
Demolition Painting ❑ Sign Other
District: DDerby Street Lafayette Street OMcIntire DWashington Square
Address of Property: 15 Chestnut Street,Salem,MA 01970
Name of Record Owner(s): Peter Gordon and Karen Hayes
Owner Mailing Address: 15 Chestnut Street,Salem,MA 01970
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
Chimney to be repointed and repaired.
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Name of Applicant: + /wnerE]ContractorE]Tenant ather:
Signature: �. � Date:
Tel. #: E-mail Address: �13 eVaA
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 W)lication may result in a continuation to ajuture 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
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