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Salem Historical Commission r O U N I � D�v E LO P��E N T
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619.5685 FAX(978)740-0404
APPLICATION FOR A CERTIFICATE 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 for.
0 New Construction ❑ Moving ❑ Reconstruction
Alteration
❑ Demolition
❑ Painting 0 Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street clntire 0 Washington Square
Address of Property: ��✓ �T
Name of Record Owner(s):
Owner Mailing Address: { E ✓VI pl q c�
Description of Work Proposed
Plea-s e. lJPe or print clearlf:Attach ad&tio»al sheets, as necessajj:
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Name of Applicant: ❑Owner ❑Contractor ❑Tenant ❑Other:
Signature: Date:
Tel. #: E-mail Address:
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 com lete a) lication main result in a continuation to a uture meetinc.
Recommended information includes:
VII
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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