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 briefly 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):
Project Review:
Approved
Denied
Referred to CHC
COA Fee
$
Other Fee:
$
Issued By: Date:
9.3% Surcharge:
$
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 Minor (Staff) Project Application
Development Services
Planning Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.6194
click to sign
signature
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