ࡱ> 5@ bjbj22 XX)Tdddne*fD~*h|kkkk=n,inn|||||||$<R~|!sm|=n!s!s|kk}ttt!s kk|t!s|t&tttkh . {d+s^tu~0D~t s6 t t,n,otpCqnnn||DLRNt RN STATE OF MAINE MAINE HISTORIC PRESERVATION COMMISSION SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2 DESCRIPTION OF REHABILITATIONMHPC Office Use OnlyMHPC Office Use OnlyNRIS No:Project No:Instructions: Read the instructions carefully before completing the applications. No certifications will be made unless a completed application form has been received. Type or print clearly in black ink. If additional space is needed, use continuation sheets or attach blank sheets. A copy of this form may be provided to fb88 Revenue Services. The decision by the Director with respect to certification is made on the basis of the descriptions in this application form. In the event of any discrepancy between the application form and other, supplementary material submitted with it (such as architectural plans, drawings, and specifications), the application form shall take precedence. 1.Name of Property:  FORMTEXT       Address of Property: Street  FORMTEXT       City  FORMTEXT       County  FORMTEXT       State  FORMTEXT       Zip FORMTEXT        FORMCHECKBOX  Listed individually in the National Register of Historic Places; give date of listing:  FORMTEXT        FORMCHECKBOX  Located in a Registered Historic District; specify:  FORMTEXT       Has a Part 1 Application (Evaluation of Significance) been submitted for this project?  FORMCHECKBOX  yes  FORMCHECKBOX  noIf yes, date Part 1 submitted:  FORMTEXT       Date of certification:  FORMTEXT       SPRCA Project Number:  FORMTEXT       2.Data on building and rehabilitation project:Date building constructed:  FORMTEXT       Floor area before rehabilitation:  FORMTEXT       Type of construction:  FORMTEXT       Floor area after rehabilitation:  FORMTEXT       Use(s) before rehabilitation:  FORMTEXT       Aggregate sq. feet of housing before rehabilitation: FORMTEXT       Proposed use(s) after rehabilitation:  FORMTEXT       Aggregate sq. feet of housing after rehabilitation: FORMTEXT       Project/phase start date (est.):  FORMTEXT       Completion date (est.):  FORMTEXT       3.Project contact:Name  FORMTEXT       Street  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Daytime Telephone Number  FORMTEXT       4.Owner:I certify on penalty of criminal punishment under the laws of the State of fb88 and the United States that I own the property described above, and that the information I have provided is true and accurate to the best of my knowledge and belief.Name  FORMTEXT       Signature Date  FORMTEXT       Organization  FORMTEXT       Street  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Daytime Telephone Number  FORMTEXT       MHPC Office Use OnlyThe Director of the fb88 Historic Preservation Commission has reviewed the Small Project Rehabilitation Certification Application Part 2 for the above-named property and has determined: FORMCHECKBOX that the rehabilitation described herein is consistent with the historic character of the property or the district in which it is located and that the project meets the Secretary of the Interiors Standards for Rehabilitation. This letter is a preliminary determination only, since a formal certification of rehabilitation can be issued only to the owner of a certified historic structure after rehabilitation work is completed.  FORMCHECKBOX that the rehabilitation or proposed rehabilitation will meet the Secretary of the Interiors Standards for Rehabilitation if the attached conditions are met. FORMCHECKBOX that the rehabilitation described herein is not consistent with the historic character of the property or the district in which it is located and that the project does not meet the Secretary of the Interiors Standards for Rehabilitation. A copy of this form may be provided to fb88 Revenue Service.    Datefb88 Historic Preservation Commission Authorized SignatureMHPC Office/Telephone No.  FORMCHECKBOX  See Attachments STATE OF MAINE SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2  FORMTEXT      Property NameMHPC Office Use Only FORMTEXT      Project No:Property Address5. DETAILED DESCRIPTION OF REHABILITATION / PRESERVATION WORK  Includes site work, new construction, alterations, etc. Complete blocks below.NUMBER 1 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 2 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 3 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 4 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).STATE OF MAINE SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2  FORMTEXT       Property NameMHPC Office Use Only FORMTEXT      Project No:Property Address NUMBER 5 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 6 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 7 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 8 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).STATE OF MAINE SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2  FORMTEXT       Property NameMHPC Office Use Only FORMTEXT      Project No:Property Address NUMBER 9 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 10 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). 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Drawing no(s).NUMBER 12 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).STATE OF MAINE SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2  FORMTEXT       Property NameMHPC Office Use Only FORMTEXT      Project No:Property Address NUMBER 13 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 14 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 15 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 16 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s). STATE OF MAINE SMALL PROJECT REHABILITATION CERTIFICATION APPLICATION PART 2 Property NameMHPC Office Use Only FORMTEXT      Project No:Property Address NUMBER 17 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s).NUMBER 18 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). 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Drawing no(s).NUMBER 20 Architectural feature: Approximate date of feature: Describe existing feature and its condition: Describe work and impact on existing feature: Photo no(s). Drawing no(s). 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