City of Madison, IN
Historic District Board of Review
Application for Certificate of
Appropriateness (COA)
For Sta Use Only
HDBR Meeng Date: _______________
Acon: ______ HDBR/Sta COA
______ HDBR Extended
______ HDBR/Sta Denied
______ Sent to HDBR by Sta
Date Received:
Applicaon Requirements
All exterior changes visible from the
public right-of-way (streets/alleys) within
the Madison Historic District requires a
Cercate of Appropriateness (COA).
Applicaons must be complete before
the HDBR or Sta can begin the review
process. Submit this applicaon form, all
supplemental documentaon as required
(see page 2), and the applicaon fee.
Applicaon Deadline
Applicaons for January-November are
due by 4:00 p.m. on the rst Monday of
the month. Applicaons for December
are due by 4:00 p.m. on the fourth
Monday of November.
Applicaon Submission
Return one copy of this completed
applicaon, applicaon fee, and all
supporng documents to:
City of Madison, IN
Oce of Historic Preservaon
101 W. Main St., Madison, IN 47250
Phone: (812) 274 - 0283
Fax: (812) 265 - 3349
Email: preservaon@madison-in.gov
A fee is not required for Sta review
projects. Please check with sta before
wring a check. The applicaon fee
(payable by cash or check made out to
Madison City Plan Commission) is $15.00
for projects which require HDBR Review
and $2.00 for each nocaon sign.
Applicaon Hearing
Complete applicaons submied by the
deadline will be heard before the
Madison Historic District Board of
Review at their regular meeng held
every fourth Monday of January—
November and on the third Monday of
December. The meengs are at 5:30 p.m.
in the City Hall, 101 W Main St, Madison,
IN 47250.
*Applicant Mailing Address:
Name(s):______________________________________________________________
Mailing Address:________________________________________________________
(Street Number - Street Name - City - State - Zip Code)
Phone Number:__________________ Email Address:________________________
Owner Mailing Address:
Name(s):______________________________________________________________
Mailing Address:________________________________________________________
(Street Number - Street Name - City - State - Zip Code)
Phone Number:___________________ Email Address:_______________________
*Note: If the applicant is not the owner, the legal noce and nocaon signage will include both the
Applicant’s name and the Owner’s Name. Applicants must have owners permission to do proposed work.
Project Informaon
Address of property for proposed work: ____________________________________
(Street Number - Street Name)
Type of Project (Check all that apply):
Contractor: ___________________________________________________________
[ ] New Building
[ ] Addion to Building
[ ] Rebuilding, Restoraon,
Rehabilitaon, Remodel
[ ] Fence or Wall
[ ] Sign
[ ] Relocang a building
[ ] Demolion
[ ] Other _______________________
Please read the following statements. Your signature below acknowledges that you
have read the statements and aest to their accuracy:
• I understand that the approval of this applicaon by City Sta or the HDBR does
not constute approval of other federal, state, or local permit applicaons.
• I understand that I (or my representave) will need to aend the HDBR Hearing.
If no representaon is present at the meeng, the applicaon will be deemed
incomplete and will be placed on the next month’s agenda.
• I have reviewed the City of Madison’s “Historic District Guidelines” in preparing
this Applicaon.
___________________________________ _________________
Signature of Applicant/Owner Date
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signature
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