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Community pevefppm nt <br />I.nui.t ills ,..I„_,i, i-cr•s.',12, • ni 'OS 4E&7•11•ww buatiM.ro.90v <br />HISTORIC PRESERVATION PROGRAM INTAKE FORM <br />APPLICATION TYPES <br />ADDRESS <br />vtf st <br />LoutSV1nC <br />co Q002q <br />APPLICANT INFORMATION <br />Name S hp; t 1eut ie- <br />mina. 1005 ce a <br />fr <br />K�o co 302 <br />e:f Toephor3 444 yldt anIb) <br />Sn3 *gat 3G60 reel <br />Emil <br />AFIklYa &aneear <br />5ikei Vviiue <br />OWNER INFORMATION (I not applicant) <br />Name <br />Address <br />Tefep'ane <br />Ems.' <br />(Owner STawe <br />NISMrC SM+cG:re AeSefaTMa <br />O Landmark <br />❑ wstatc Preservation Full Gert <br />O YiS'O6C Preservatan Fund Loan <br />O Atwater Certificate <br />p Oemodton Reeve <br />NOTES <br />CERTIFICATIONS. <br />By ntahng below. I certify that. <br />-1 understand that any grants provided by <br />the City may - De 9otnted as income 'ce tax <br />purposes. <br />• I am the owner of the property at the <br />address abOvo, or have been authorized <br />by t e owner to make an application iV <br />-1 understand that only the property owner <br />may be jeimbursed for any and all gams <br />