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Historical Preservation Division. Planning staff can answer any (DigitalOcean)

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  • 10 check-boxes
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COMMUNITY SUSTAINABILITY
PLANNING ZONING HISTORIC PRESERVATION
1900 2ND AVENUE NORTH
LAKE WORTH BEACH, FL 33461
561.586.1687
Planning, Zoning & Historic Preservation Division | Department for Community Sustainability
City of Lake Worth Beach | 1900 2
nd
Avenue North | Lake Worth Beach, FL 33461
This application is required for ALL applications submitted to the Planning, Zoning and
Historical Preservation Division. Planning staff can answer any questions you have regarding the
applications and the processes.
NOTE: PRE-APPLICATION MEETING REQUIRED FOR ALL CASES TO BE REVIEWED BY THE
HISTORIC RESOURCES PRESERVATION BOARD. PLEASE CALL 561.586.1687 OR EMAIL
HISTORICPRESERVATION@LAKEWORTHBEACHFL.GOV TO REQUEST AN APPOINTMENT.
Application Type (select all that apply):
Exterior Alterations (roof, windows, doors, etc.)
Addition New Construction Demolition Relocation
Other:
PROJECT INFORMATION
Project Location:
Legal Description: ___________________________
PCN: 38-43-44-___-___- - Historic District: _________ Contributing?:
# of buildings/structures on property: ___ What type?: _____________________________________
Current Use: _____________________ __ Change of Use Proposed?: __________________________
Total Estimated Cost of the Project:
Are you requesting consideration of Economic Hardship? ____ If yes, please include required checklist.
FOR OFFICE USE ONLY
HRPB Project No.
Associated Project Nos.
Submittal Date
Sufficiency Date
Project Planner Assigned
Total Fee Amount
$ _______________ PAID ______________ DUE _____________
CERTIFICATE OF APPROPRIATENESS APPLICATION
Certificate of Appropriateness Application Page 2 of 4
APPLICANT INFORMATION
Project Manager/Contact Person:
Company:
Address:
(Street Address) (City) (State) (Zip)
Phone No.: E-Mail Address:
Applicant Name (if different from Project Manager):
Company:
Address:
(Street Address) (City) (State) (Zip)
Phone No.: E-Mail Address:
Owner Name:
Address:
(Street Address) (City) (State) (Zip)
Phone No.: E-Mail Address:
OWNER’S CONSENT (IF APPLICABLE)
(“Owner”) certifies that it is the owner of the property
located at
(“Subject Property”) and expressly consents to the use of the Subject Property as described in this
application and to all conditions that may be agreed to as a part of the approval of this application,
which may be imposed by the decision making board.
Owner hereby authorizes , as agent, to file this application
and represent Owner at any and all meetings and hearings required for the approval of this application.
Owner’s Signature: Date:
Name/Title of Signatory:
STATE OF )
COUNTY OF )
The foregoing instrument was acknowledged before me this _______ day of _____________________, 20__, by
________________________________________ who is personally known to me or who produced a
______________________________ as identification. He/she did not take an oath.
(NOTARY SEAL)
(Signature of Notary Public)
(Name of Notary)
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Certificate of Appropriateness Application Page 3 of 4
PROJECT INFORMATION
DESCRIPTION OF WORK:
Provide a detailed description of work to be done as a result of this application (attach additional sheets if necessary).
PRIOR APPROVALS:
Indicate any prior planning, zoning, historic or building approvals that you are aware of for the property (attach additional
sheets if necessary).
APPLICATION INSTRUCTIONS
CERTIFICATE OF APPROPRIATENESS APPLICATION
• Fill in all applicable fields and do not forget to include all required signatures.
APPLICATION CHECKLIST
• Include all additional items as specified on each project specific application checklist if
applicable.
ĚĚŝƚŝŽŶĂůinformation may be required by Staff depending on the scope of each project.
Certificate of Appropriateness Application Page 4 of 4
AFFIDAVIT OF COMPLETENESS AND ACCURACY
INSTRUCTIONS: To be completed by the individual submitting the application (owner or authorized agent).
Project Location: Submittal Date:
STATEMENT OF COMPLETENESS AND ACCURACY:
I hereby certify all property owners have full knowledge the property they own is the subject of this application. I
hereby certify that all owners and petitioners have been provided a complete copy of all material, attachments
and documents submitted to the City of Lake Worth relating to this application. I further certify the statements or
information made in any paper or plans submitted herewith are true and correct to the best of my knowledge. I
understand this application, related application material and all attachments become official records of the
Planning, Zoning and Historic Preservation Division of Lake Worth, Florida, and will not be returned. I understand
that any knowingly false, inaccurate or incomplete information provided by me will result in the denial, revocation
or administrative withdrawal of this application, request, approval or permit. I further acknowledge that additional
information may be required by Palm Beach County to process this application. I further acknowledge that any
plans that I have prepared or had prepared comply with the Fair Housing Standards. I further consent to the City of
Lake Worth to publish, copy or reproduce any copyrighted documents submitted as a part of this application for
any third party. I further agree to all terms and conditions, which may be imposed as part of the approval of this
application.
Check () one: I am the property owner authorized agent.
(Name - type, stamp or print clearly) (Signature)
(Name of Firm) (Address, City, State, Zip)
STATE OF )
COUNTY OF )
The foregoing instrument was acknowledged before me this _______________ day of _____________________,
20__, by ________________________________________ who is personally known to me or who produced a
______________________________ as identification. He/she did not take an oath.
(NOTARY SEAL)
(Signature of Notary Public)
(Name of Notary)
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Completed 26 May 2022

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