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f <br />1=M <br />Date Received: 0/,U 'l.D Application Number: du -f <br />t , <br />Past Reviews: EI YES (Ntt rxf t aft xe,1"q NO <br />StaffApprovol authorized by: 'Title: <br />Historic Preservation Commission Review Date: <br />El Local Landmark ❑ Local Historic District (m me) <br />National Landmark National RegisterDistrict(N"e) <br />Certificate of Appropriateness: <br />El Denied F1 Tabled 11 Sent To Committee Approved and Issued: <br />(Please Print) <br />Address of Property for proposed work: t1> <br />(Street Number- Street Name-City -Zip Code) <br />Name of Property Owner(s): en �{�, � I �) � Phone N: . i <br />Address of Property Owner(s): <br />(Street NumbetJ- Street Name - City -Zip Code) <br />Name of Contractor(s): <br />Contract Company Name: <br />Phone #: <br />Address of Contract Company; <br />(Street )vumber- -- Street Name - City -Zip Code) <br />Current Use of Building: / tx �L t ' r t~. <br />` (Single Faml -- Mufti• Famlly - mmerrial -Gmfe went-- tndustrial Vacant- -etc.) <br />Type of Building Construction: l -6 �n '7fi4 P <br />OYood Frame- Brick- Ron"teel- Concrete - Other) <br />Proposed Work: Fi In -Kind ❑ Landscape New ❑ Replacement (not in- kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: C ; 7 7 7 g - 7 c` °t`+ t? c L'`' 7 <br />Owner/Contractor Fax e - mail: C cle I c L`� ��• I C t � - <br />(Staff will sort spond with only on esignee) <br />X, and/or X <br />Signature of Owner Signature of Contractor <br />-- APPLICATION REQUIREMENTS ARE LISTED ON RIEVERSE SIDE -- <br />