Southbury Historic District Commission No. 1, Southbury, Connecticut
Application for
Certificate of Appropriateness
Date: Application Number:
Owner(s) Name(s):
Street: Street Number:
Plot Number: Owner’s Phone Number:
Owner’s Address:
(If different from above)
Type of Structure: Dwelling Outbuilding
(Check one)
Parking Other (please specify below)
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Nature of work: New Remodeling
Work to be done by: Owner Contractor
Estimated Project Dates: Start Finish
Description of Work to be done: (as it affects exterior appearance). Please attach additional
information to describe your project, such as architectural drawings and photographs.
The Historic Commission reserves the right to request additional information, as necessary.
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Signature of Owner or Authorized Agent
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