81 Derby Street application Date Stamp
FEB 9 2016
Salem Histojzcal Cojjamissi?KEPT. OF LANNING &
MUNITY EVELOPMENT
120 P✓ASHINGTON STREET,SALEM,MASSACHUSETTS 01970 For Office Use Only
(978)619-5665 FAX(978)740-040
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 ❑ Painting ❑ Sign ❑ Other
District: ❑Derby Street ❑Lafayette Street OMclntire ❑Washington Square
Address of Property: 91 —1 ) fle-,Rt/
Name of Record Owner(s): it 4-hL4 ICh a/1 rl N /U tC i s 7 /;L
Owner Mailing Address:
Description of Work Pronosed
Please 07)e or print clearl}: Attach additional sheets, as necessarjc
vGG ZFCGN.CrlLLP 1/a•A Grr1 Sf (/F/Irt�j [�S i�•'/CI d2�1 jFD 2 �/I.N/L
Name ofAppl'canttJ: N11'OL5 /1crf ❑Owner ❑Contractor ❑Tenant XOther:�$C%lvr/j
SignatureC. ( >c 4NrFr_�y/I� �N Date: Z17 /,
Tel. #:- G / - �`7-9- Z 6 E-mail Address: 4-�NN�O a�o 1<C CM ,
Certificate will be mailed to the owner unless otherwise indicated he e.
Certificate should be mailed to: Name ,/'�n/l/c,k " 'AS'^s
Mailing address: l 6 K-a/t�wOo �/�of City:J/i,14 P"CA P/iR)Stated Zip: �Z�3�
ATTACHED DOCUMENTATION
B
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:
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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