Please print legibly or type
DATE: PROJECTNO: APPLICATONNO:
HP –
APPLICANT’SNAME: PROPERTYOWNER’SNAME:
APPLICANT’SADDRESS: PROPERTYOWNER’SADDRESS:
CITY,STATE,ZIP: CITY,STATE,ZIP:
TELEPHONE(INCLUDINGAREACODE): TELEPHONE(INCLUDING AREACODE):
EMAILADDRESS: EMAILADDRESS:
PRIMARYCONTACTPERSON:
Applicant Property Owner
I, the undersigned, declare under penalty of perjury under the laws of the State of California that the information on this Certificate of Appropriateness
application is true and correct. In addition, I understand that by nominating the subject property for landmark designation I cannot proceed with any
environmental changes unless and until a Certificate of Appropriateness is issued by the Cultural Heritage Commission or the Historic Preservation
Office. I further understand that neither this application nor a subsequently issued Certificate of Appropriateness supersedes the need to obtain the
necessary building permits and other applicable permits under the City of Long Beach Municipal Code.
Signature: Date:
1. PROPOSED LANDMARK
NAMEOFPROPOSEDLANDMARK: ASSESSOR’SPARCELNUMBER: COUNCILDISTRICT:
PROPERTYADDRESS: COMPLETELEGALDESCRIPTION:
TRACT BLOCK LOT(S)
PRESENTUSE: ORIGINALUSE:
2. SUBMITTAL REQUIREMENTS
COMPLETED APPLICATION (PAPER WITH ORIGINAL SIGNATURE) PHOTOGRAPHIC RECORD OF PROPERTY (ELECTRONIC)
[OPTIONAL] COMPLETED DPR FORM 523A, 523B (ELECTRONIC)
SITE PLAN OF SUBJECT PROPERTY (ELECTRONIC)
(
FLOOR PLANS, IF INTERIOR DESIGNATION)
COPIES OF HISTORIC PHOTOS, PLANS, OR OTHER INFORMATION (ELECTRONIC)
FOR DEPARTMENT USE ONLY BELOW THIS LINE
Reviewed By: Date:
Submittal Complete
COA Fee:
$
Submittal Incomplete
9.3% Surcharge:
$
CHC Date:
TOTAL: $
This information is available in alternative format by request to (562) 570.6194.
For an electronic version of this form, v
isit our website at longbeach.gov/lbds.
Certificate of Appropriateness Landmark Nomination Form
Development Services
Planning Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.6194
