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2. Longmeadow Historic District Commission
4. Application For Certificate
5. Date/Time
   Date/Time

   Date/Time
7. Please check the certificate applied for:

   1. Certificate of Appropriateness
   2. Certificate of Non-applicability
   3. Certificate of Hardship
   4. Extension of Previously Approved Application
   5. Amendment to Previously Approved Application
9. Owner:
11. First Name
12. Last Name
14. Address of property
16. Owner's Address (If different from property address):
18. City
19. State
20. Zip
22. Owner's Phone:
23. Email
25. Applicant (If different from owner):
26. Written Proof of Owner Authorization

    Please provide written proof of owner authorization. *This field is only required if the owner is not the applicant.

28. First Name
29. Last Name
31. Address1
33. City
34. State
35. Zip
37. Applicants Phone
38. Email
40. List abutters
42. Description of Proposed Work

    Please be specific. (If Extension of or an Amendment to a Previously Approved Application please include Application Reference Number)

43. Supporting Documents

    Please include plans, photos, samples, drawings, or other devices to aid in the Commission’s understanding of the project here

45. Signature

    By signing you agree to the following: All improvements shall be carried out as shown on the plans and specifications submitted by the applicant, except as modified and listed in the final issued certificate, all work shall be completed within 1 year of the application date (if you are unable to do this you may file for an extension), and you hereby agree to comply with the terms and conditions of this application. Please print your name as proof of consent.

47. Signature of Applicant
48. Signature of Owner (If different than applicant)
50. Date
    Date

    Date
51. Date
    Date

    Date
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field