osiieia01g 13:47 State St. Brust Pans 78 0021008 Fora valid application it must conta the following information: Type of Certificate petitioner is seeking must be indicated ~Ovmer's signature must appear on the Application ~-PHIOTOS, MATERIALS, and PLANS specified on the ee Application instruction sheets, SAS Tcompete applications will NOT be aceptd some povmommiariness iar APPLICATION FOR CERTIFICATE OF: HARDSHIP (Geto) NOWarrcamaTY 8230 - 0002 11 the putitone wil eg an inert For Historical Commission Use © _Mmaplswood “Eee, Commision adress oF Property Da TT ae Dovid we Moon Sib [aor One =a - (36 Tok Vlanmot Out ol ai/fow Reng Seringemase tase. 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