6 Chestnut Street Cof NA application Date Stamp
I
�i
Salem Histm cal Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
(976)619-6655 FAX(976)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:
❑ New Construction ❑ Moving ❑ Reconstruction ❑ Alteration
❑ Demolition ,2l', Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street ` IcIntire ❑Washington Square
Address of Property: � „t .._�
Name of Record Owner(s):
Owner Mailing Address: Cti t —ft c < <i v ¢ ��r- Q r S -7e>
Description of Work Proposed
Please lipe or prtiit clearl}: Attach additional sheets, as necessajj:
r `zt �i �
13
t,V !/t I N t �, �L t' ` C- r vt S lS2 V P t•7 �•
Name of Applicant:t1t.vy ,'Owner ❑Contractor ❑Tenant ❑Other:
Signature: - Date: :74q
Tel. #:_ � 'Z Y Z ti � e ,� E-mail Address: ` :3 !- , C h7
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailingaddress: _
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 application may result in a continuation to a future meetine
Recommended information includes:
a
tos of existing conditions, taken from all public ways
plan showing location of improvements
ation drawings of the existing conditions and proposed improvementsings 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
I
t
1
C
A
�'i
�.a E+
I
.�
,o
- - j
i b`..,.
, �
,�,r
w
�.� I • •�J/• j per
I of r
J low��
An
.
r ti
�� "`ram. ■rr�
' - �„ 410k ,,,