148 Derby Street Application.10282016 Date Stamp
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Salem Historical Commission
For Office Use Only
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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:
11 New Construction 11 Moving Ll Reconstruction 11 Alteration
J Demolition Painting EJ Sign U Other
District: Y'Derby Street []Lafayette Street I McIntire II Washington Square
Address of Property: 1118 b C,-,6 y 5 7ME 6-11-
Name of Record Owner (s): DftZGX 101Zoff12r1C_S Z-6c
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Owner Mailing Address:
Description of Work Proposed
Please type orpr print clearly.Attach additional sheets, as necessary.
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Name of ALLG
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r"afl�e"V5'466er OContractor []Tenant 00ther:
Signature- Date: Id—Z&I'll-
Tel. #: 11 q-7 E-mail Address: r'1').7-,r-z 1 eAz- CizJ
Certificate will be mailed to the owner unless otherwise indicated here:
Certificate should be mailed to: Name
Mailing address: CitY:_-f19-0F1" State:�Zip: c-))"
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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 may result in a continuation to a future meeting
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