343 Essex St Strack Date Stamp
Salem Historical Commission 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:
New Construction - Moving - Reconstruction - Alteration
Demolition - Painting - Sign )7 Other
District: Derby Street Lafayette Street T %Watire Washington Square
Address of Property:
Name of Record Owner(s): Pq a/) 517Q4 e A,,
Owner Mailing Address: ram- a S (�G' he ✓e
Description of Work Proposed
Please type or print clearly. Attach additional sheets, as necessary.
Name of Applicant: Owner VContractor Tenant J Other:
Signature: GG <,,/ , I Date:
Tel: #:- `/x0'�N9- b�`7�`� E-mail Address:-, ee /1 �?�C01lhFe>✓Su)¢�US•
Certificate will be mailed to the owner unless otherwise indicated here.n
Certificate should be mailed to: Name (� n
Mailing address: �� ��l.t/!5 � � City: • t StateA_Zip: TA
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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 infon-nation 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 21*x2")
Location and size of all mechanical equipment, such as transformers. HVAC equipment,
electrical service and meters, and proposed screening