Please print legibly or type
DATE: PROJECT NO: CASE NO:
HP
PROJECT ADDRESS (NOT MAILING LIST): HISTORIC DISTRICT/LANDMARK NAME:
APPLICANT’S NAME: PROPERTY OWNER’S NAME:
APPLICANT’S ADDRESS: PROPERTY OWNER’S ADDRESS:
CITY, STATE, ZIP: CITY, STATE, ZIP:
TELEPHONE (INCLUDING AREA CODE):
TELEPHONE (INCLUDING AREA CODE):
EMAIL ADDRESS: EMAIL ADDRESS:
PRIMARY CONTACT PERSON:
Applicant Property Owner
Please check the appropriate boxes below.
Only check a box if it accurately and describes your proposed work, otherwise leave boxes blank.
In addition, please briefl
y describe your project noting materials, colors, location, and type of work proposed.
Also note the reason for the requested modification.
1. PROPOSED PROJECT
New Construction Relocation Addition Signage/Awning
Restoration/Rehabilitation Alteration Demolition Other:
2. PROJECT DESCRIPTION
3. REASON FOR CHANGE(S)
TOTAL SQUARE FEET OF THIS PROJECT:
COMM
RES GAR MISC
VALUATION OF WORK COVERED BY THIS APPLICATION:
$
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 I cannot proceed with the environmental changes requested in this application unless
and until a Certificate of Appropriateness is issued by the Cultural Heritage Commission or the Historic Preservation Officer. 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:
FOR DEPARTMENT USE ONLY BELOW THIS LINE
CEQA Review:
Exempt Pending Completed (note type):
Submittal Complete
COA Fee:
$
Reviewed By: Date:
Submittal Incomplete
9.3% Surcharge:
$
CHC Date:
TOTAL: $
This information is available in an alternative format by request to the Development Services Center at
(562) 570-6194 – Visit our website at longbeach.gov/lbds
Certificate of Appropriateness Major (CHC) Project Application
Development Services
Planning Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.6194
click to sign
signature
click to edit
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