171 Federal St - C of A application for chimney removal Date Stamp
DEC 04 2017
Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
f978)619-6685 FAX 1978)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 E] Moving E] Reconstruction Alteration
Demolition 0 Painting 0 Sign [-] Other
District: E]Derby Street E]Lafayette Street RNlclntire E]Washington Square
Address of Property: 11t Vv-r'-*4L.
Name of Record Owner(s): PWS I IUQ� 1/00NLT!�� I MA"qN c-f--vjN1F--
Owner Mailing Address: t FVVM2Ak'- 5-r-
Description of Work Proposed
Please type orprhit clearly.Attach ad&lional sheets, as Necessary.
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Name of Applicant: r9(WnerE]Contractor[]Tenant ather:
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 complete a lication may result in a continuation to a future meetin .
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)
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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