125DERBY- CofNA-RepairWork-RoofChimney Date Stamp
Is
Salem Historical Commission
120 WASHINGTON STREET.SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619-5685 FAX(978)740-0404
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 �K Reconstruction ❑ Alteration
❑ Demolition ❑ Painting ❑ Sign ❑ Other
District: Derby Street ❑Lafayette Street ❑McIntire ❑Washington Square
Address of Property: 125 Derby Street
Name of Record Owner (s): 125 Derby Street Condo Association
Owner Mailing Address:
125 Derby Street,Salem,MA 01970
Description of Work Proposed
Please type orprmt cle ily.Attach additional sheets, as necessary.
The work will repair leaks in the chimney,roof,and the interface between the two.
-The flashing between the roof and the chimney will be replaced.
-The chimney will be repointed as necessary.
-The missing shingle caps on the northeast hip will be replaced.
No repairs will atler the appearance of the structure,except for the last,which will restore the structure to its
appearance before the damange.
Pictures can be found at http://haselgrove.org/ch/125_roof/.
Name of Appqca : Christian Haselgrove(for condo assoc) ❑Owner❑Contractot❑Tenant❑Other:
Signature: Date: 6 ID
Tel. #: 617-416-4390 E-mail Address: christian@haselgrove.org
Certificate will be mailed to the owner unless otherwise in icated here:
Certificate should be mailed to: Name Christian aselgrove
Mailing address: 125 Derby Street City: Salem State: M Zip: 01970