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Cityof Om Louisville <br />COLORADO • SINCE 1878 <br />Community Development <br />749 Main Street • Louisville CO 80027 • 303.335.4592 • wvirw.louisvilleco.gov <br />HISTORIC PRESERVATION PROGRAM INTAKE FORM <br />ADDRESS <br />/(3,2 &0 /2 <br />ifs Yi lie - <br />APPLICANT INFORMATION <br />Name: J4'm44 e. 6C-4G'ls <br />Address: J -r 57' <br />, <br />Telephone: . O 3 - -35-6 - 02- <br />Email:. P/5 . 7' <br />Applicant S' • nature: <br />OWNER INFORMATION (if not applicant) <br />Name: <br />Address: <br />Telephone: <br />Email: <br />Owner Signature: <br />APPLICATION TYPES <br />❑ Historic Structure Assessment <br />te Landmark <br />kr Historic Preservation Fund Grant <br />❑ Historic Preservation Fund Loan <br />❑ Alteration Certificate <br />❑ Demolition Review <br />NOTES <br />tom- 51-reci- <br />-67) era e�-S <br />% GAL c5e_ <br />CERTIFICATIONS: <br />By initialing below, I certify that: <br />- I understand that any grants provided by <br />the City ma -be counted as income for tax <br />purposes. <br />- I am the owner of the property at the <br />address above, or have been authorize <br />by the owner to make an application. <br />- I understand that only the property owner <br />may be reimbursed for any and all grants. <br />