12 Chestnut St application for landscape screen Date Stamp
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Salem Hishnical Commission
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APPLICATION FOR A CER7ITFICATE OF APP1,20PRIATENESS
Pursuant to the Historic Districl's Act (M.G.L. Chapter 40C) and the Salem Historical Commission Ordinance,
application is hereby made for iasuance of a Certificate of Appropriateness for:
❑ Ne"�:,v Construction E] Moving [7 Reconstructien Alteration
❑ Demolition ['' Painting ff] Sign Other
District: ❑Derby Street Lafayette Street �tmclntire ❑Washington Square
Address of Property: _]Z CAAE5NC) r 5'3Y—£ET
Name of Record Owner(s): f F—T-F-e `, H A427 Pr P rTKAN
Owner Mailing Address: 17" _ Cx4E5TNt7"V 'S.L SALEK t LM C7l1--0
Description of Work Proposed
Please I[PC or print dear/. fltwelt additional shee,s, as necessall.
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Name ofA,pplicant: c. Owner❑Contractor❑Tenant❑()ther: _
Signature: Date;
Tel. #:
8. (;'JI S 5�I� E-mail. Address: F �rt l° „rn. [cws .
Certificate wlll be mailed to the oxme., unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing adldress: _, _, City:_ State:_Zip:
f ATTACHED DOCUMENTATION
An application All not be considered complete unless all work items are thoroughly described and the application
includes all infr;lrmation needed f or the Commission to make a determination.
Failure to submit a complete application may result in a continuation to a future meeting
Recommended information includes:
Photos of existing conditions,taken fi•om 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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