Certificate Of Appropriateness & Building Demolition Delay Waiver Checklist - Worcester Historical Commission Page 2
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1
2WORCESTER HISTORICAL COMMISSION
CERTIFICATE OF APPROPRIATENESS & BUILDING DEMOLITION DELAY WAIVER APPLICATION
(For properties located in the
Massachusetts Avenue or Montvale Local Historic District)
Planning & Regulatory Services Division ● 455 Main Street, Room 404; Worcester, MA 01608 ● Phone: 508-799-1400, ext.
Office Hours are 8:30 am – 2:00 pm
1. Building Location: ____________________________________________Date: ________________________
2.
Montvale or Massachusetts Local Historic District: ____________________________________
3. Date or Estimation of Original Construction: ___________________________________________________
4. Description of Work (please list and explain each proposed change separately. Attach additional pages if
necessary. If replacing with like materials, note accordingly):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. Owner of Property: ____________________________________________Phone: ______________________
Address: ________________________________City: ___________________________Zip: _______________
6. Contractor: ____________________________________________________ Phone: ____________________
Address: ________________________________City: ___________________________Zip: _______________
7. Type of Building Construction: ______________________________________________________________
(Wood, Concrete, Steel, Etc.)
8. List all the Uses of the Building:______ _________________________________________ # of Stories: ___
(Residence, Business, Industrial, Etc.)
9. Code Violations/Health/Safety Issues: ________________________________________________________
___________________________________________________________________________________________
10. Reasons for full or partial demolition (i.e. changes to the exterior) including other alternatives explored:
__________________________________________________________________________________________
___________________________________________________________________________________________
11. Economic Hardship, if applicable (usually is used when replacement is proposed in place of restoration of the
original historic materials, features, or structures. Detailed cost estimates & comparisons of replacement v.
restoration may be attached separately for the Commission’s review):
___________________________________________________________________________________________
___________________________________________________________________________________________
Owner’s Signature certifying that the above information is true and accurate to the best of his/her knowledge:
___________________________________________________________________________________________
Date:____________________________
Page 2 of 2
Certificate of Appropriateness & Building Demolition Delay Waiver
Revised:
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