Cof NA application - 1 Chestnut St Date Stamp
RECEIVED
OCT 202016
D PT. OF PLANNING &
Salem Historical Commission COMMUNITY DEVELOPMENT
120 WASHNGTON STREET SALEM MASSACHUSETTS 01970 For Office Use On1v
(978,619.5685 FAX 974-740-040
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 Alteration
Demolition Painting Sign ® Other
District: Derby Street QLafayette Street foMclntire Washington Square
Address of Property: C T��" ✓�«'"'� -y
Name of Record Owner(s):
Owner Mailing Address:
Description of Work Proposed
Please type or print clearly.Attach additional sheets,as necessary.
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Name of Applicant:c,'Ale 00wnerOContractorOTenantQOther:
Signature: Date:
Tel. #: '' u�J �—' C - E-mail Address: -7 �' �` ,
Certificate will be mailed to the owner unless otherwise indicated here
Certificate should be mailed to: Name
Mailing address: C�� fT City: '` StacEe:!�
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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 mrai-result in a continuation to afuture meeting
Recommended information includes:
L Photos of existing conditions,taken from all public ways
I
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