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•
TIFICAT
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F APPROPRIATE
ALTE TIONS, NEW CONSTRUCTION
CITY OF A
HISTORIC AND
ENVIRONMENTAL
PRESERVATION
BOARD
NAME OF HISTORIC SITE OR HISTO:il, DISTRICT
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ADDRESS OF PROPERTY:- ( ,
9- (..5- Naz-ili 6 a Le --).6 !e Ilp-,ii .F' 33/3:?-
OWNER'S NAME i OWNER'S TELEPHONE NUMBER (DAYTIME)
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APPLICANTS NAME (IF NOT OVVN 2 / APPLICANTS EPHONE NUMBER (DAYTME)
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OWNER'S ADDRESS. CITY, ZIP CODE
APPLICANTS ADDRESS, CITY. ZIP CODE
APPLICANTS RELATIONSHIP TO OWNER
DETAILED DESCRIPTION OF PROJECT (USE ADDITIONAL PAGE IF NECESSARY)
A
06.17/ /1911)(EL — t/erk) iL)
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72 /71 /9,i, Pcg Tv) /VIA T /44 16-;/7-1 aaAvic-44
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ATTACHMENTS SUBMITTED WITH APPLICATION
0 PLANS OF PROPOSED PROJECT
iF PHOTOGRAPHS OF PROPERTY
MATERIAL SAMPLES
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0 OTHER 7A e.-, a--
I CERTIFY TO THE BEST OF MY KNOWLEDG THAT ALL INFORMATION IN THIS APPLICATION AND ITS ATTACHMENTS IS CORRECT.
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SIGNA URE OF APPLICANT (IF OTHER THAN OWNER) DATE
FOR STAFF USE ONLY:
APPLICATION NO.
jk-STANDARD CA
SPECIAL CA
DATE RECEIVED
D ARPROV D
APPROVED WITH CONDITIONS
DENIED
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DATE OF FINAL ACT710N
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