STATE HISTORIC REHABILITATION TAX CREDIT SECTIONS 1, 2 AND 3 INITIAL PROJECT APPLICATION

Refer to the Instructions to fill out the form. All fields on the form must FY Q ORDER OHP No. Note: be completed if applicable or the form will be returned. NPS No. 1. Historic Property Name: Street: City: County: Zip: Name of Historic District to which property contributes: California Register District California Register Property federal Part 1 application submission 2. Project Contact (if different from applicant) Name: Company: Street: City: State: Zip: Phone: Email Address: 3. Applicant I attest that the information I have provided is, to the best of my knowledge, correct, and that: I am the owner of the above-described property within the meaning of "owner" set forth in CCR 4859.02(k), and/or if I am not the fee simple owner of the above described property, the fee simple owner is aware of this application and has no objection, as noted in a written statement from the owner, a copy of which (i) either is attached to this form and incorporated herein, or is previously submitted, and (ii) meets the requirements of CCR 4859.02(k). I understand that willful falsification of this application is considered a felony under California Penal Code Section 115 and may subject me to fines and imprisonment of up to three years. Name: Signature: SIGN Date: Applicant Entity: Street: City: State: Zip: Phone: Email Address: continued on next page OHP Official Use Only Section 1 The OHP has reviewed the Initial Application Section 1 for the property above and has confirmed it: is listed individually or contributes to the above-named district on the California Register and is a “certified historic structure” for rehabilitation purposes. is not listed on the California Register or has been determined as a non-contributor to a District. SIGN Date OHP Comments attached Julianne Polanco, State Historic Preservation Officer OHP Official Use Only Section 2 The OHP has reviewed the Initial Application Section 2 for the above-named property and has determined that: the rehabilitation described herein is consistent with the historic character of the property and/or with the district in which it is located and that the project meets the Standards for Rehabilitation. This letter is a preliminary determination only, since formal certification of rehabilitation can be issued only to the owner after rehabilitation completion. the proposed rehabilitation will meet the Standards for Rehabilitation if the attached conditions are met. 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 Standards for Rehabilitation. SIGN R E C E I V E D Date Julianne Polanco, State Historic Preservation Officer OHP Comments attached O H P

I attest that the information I have provided is, to the best of my knowledge, correct, and that:

I understand that willful falsification of this application is considered a felony under California Penal Code Section 115 and may subject me to fines and imprisonment of up to three years.