Historical Commission Application Date Stamp
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 Other
District: ❑Derby Street ❑Lafayette Street ❑McIntire ffVa. hin on quare
Address of Property:
Name of Record Owner(s): �1Ai �1�-1dyS{IJ(OtC1 '�'1
Owner Mailing Address: 2 Girl ST. w. M or o1qJ0
Deserigtion of Work Proposed
Please t e o1-Mti�lt rlexiy.1ilpyb additlon;d steels, as.11ecessx- ,
'�d '(`�" ( -�D ` ' [ iCc�C�C v1J1 w 11.�taJ
Name of App i ant: ❑Owner❑Contractor❑TenanttWther: NM
Signature: ` Date: 1
Tel.#: E3 E-mail Address:�\jywk e,\%j \Ol A`ee �l�_ [,[�i�►�
Certificate will be mailed to the owner unless otherwise indi=ted here. C
Certificate should be mailed to: Name ' �1.7G�
r
Mailing address:r i PW W";!5C ax State:_Zip:
ATTACHED DOCUMENTATION
An application will not be considered complete unless all workitems are thoroughly described and the application
includes all information needed for the Commission to make a determination.
Faihsre to submit a complete application may result in a continuation to a fiagire 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)
QDimensions-(..e:height-o 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