21 Flint St - C of NA application - paint house Date Stamp
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Sa'.err Historical Commission DE T. OF FGGLA!�N����;ppNG &�
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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 n Alteration
Demolition Painting Sign Other
District: ❑Derby Street EjLafayette Street ®McIntire Washington Square
Address of Property: r,1 f Li A1T) S% p
Name of Record Owner(s): PAv'D 14 6-63 q TANA'A- I aptE7`
Owner Mailing Address: 2 i ''L N ST
Description of Work Proposed
(� Please type or print clearly:Altach ad(litiomd sheets, as Necessary.
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Name of Applicant: �,4V�►� /7 Yr� Downer[]ContractorQTenant Other:
Signature: r Date: 6 L f za /
Tel. #: ZD.S• g/8'• SV q 6 E-mail Address: V,'O./C4y C MAC t.
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 anplication may result in a continuation to a future meeting
Recommended information includes:
VII
XPhotos 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")
E:1 Location and size of all mechanical equipment, such as transformers, HVAC equipment,
electrical service and meters, and proposed screening
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