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Salem Historical CommissionCO MUNITY DEVELOPMENT
DEPT. OF PLANNING &
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120 WASHING70N STRFFT SAL FM MASSACHUSETTS 01970 For Dffice use n y
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(978)819-5885 FAX(9181110.0.01
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 ✓Q Reconstruction Alteration
II Demolition Painting Sign Other
District: DDerby Street Lafayette Street ✓McIntire Washington Square
Address of Property: 13 Chestnut Street
Name of Record Owner(s): Nicholas Kiefer,M.D.and Jennifer Rousseau Kiefer
Owner Mailing Address: 13 Chestnut Street
Description of Work Proposed
Please type or print clearly.Attach additional sheets, as necessary.
Repair/rebuild two chimneys (one at center of house and one at rear abutting driveway)with materials of like kind.
Work to be performed by William Lach.
Replace existing rubber roof and asphalt shingles with materials of like kind. Work to be performed by Tanner
City Contractors. See attached proposal.
Name of Applicant:Jennifer Rousseau Kiefer
pp Q✓OwnerOContractorQTenantather:
Signature: Date: (✓
Tel. #:508-728-1948E-mail Address: Jenni-mail Address: JenniferLRousseau@gmazLcom
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: City: State:_Zip:
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