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Date Certificate Issued: <br />❑ Local Landmark ❑ 'National Register Listed <br />❑ Name of Historic District: <br />Address of Proposed Environmental Change: <br />(Street Number and Street Name) <br />City, Township: <br />Name of Property Owner(s): <br />(Print) <br />Address of Property Owner <br />Contractor(s) Name: <br />Conttact,.Company Name: <br />Contractor's Telephone Number: <br />Current Use of Building: <br />(Vacant - Single Family - Multi -Family - Commercial Government - etc) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Vroposed.Work: ❑ New ❑ Building' Addition Landscape <br />❑ Demolition (Completion ofSeperate Form Also RequiredforThis) <br />Description of Proposed Work: <br />