Rev. 10/17 1 of 2 STAFF USE ONLY LPC DOCKET # : DATE RECEIVED: STAFF : ACTION : PMW CNE COFA REPORT OTHER: WORK TYPE : APPLICATION FORM FOR WORK ON DESIGNATED P ROPERTIES INSTRUCTIONS FOR FILING and its effect on the landmark property. Please read the instructions of this form carefully, and provide all the information requested for ALL 6 section s . LPC staff uses this information to aff or will require a review by the full Commission at a Public Hearing. Failure to submit complete applications with required materials will result in delays in the review and processing of your application. Filing ma y be done b y m a i l or in pers on to : ATTN: New Applications, Municipal Building, 1 Centre Street, 9 th Floor North, New York, NY 10007 . I.PROPERTY INFORMATION ADDRESS: FLOOR/APT. #: BOROUGH: BLOCK: LOT: COMMUNITY BOARD : ZONING: II.PROPOSED WORK (CHECK ALL THAT APPL Y) INTERIOR ALTERATIONS INTERIOR ALTERATIONS PLACE OF ASSEMBLY, NO WORK P ROPOSED RESTORATION & OTHER FA307ADE WORK RECREATE MISSING ARCHITECTURAL FEATURES LL11 EXTERIOR REPAIRS (check all that apply): Street fa347ade Side or rear fa347ade/roof OTHER EXTERIOR REPAIRS (check all that apply): Street fa347ade Side or rear fa347ade/roof HEATING, VENTILATION & AIR CONDITIONING EQUIPMENT WINDOW/HVAC EQUIPMENT: Street fa347ade Rear or side fa347ade THRU - WALL HVAC EQUIPMENT: Street fa347ade Rear or side fa347ade OTHER MECHANICAL EQUIPMENT: Wall mounted Yard Exterior Generator WINDOW & DOOR WORK REPLACE WINDOWS (check all that apply): Street fa347ade Rear or side facade NEW WINDOW OPENING (check all that apply): Street fa347ade Rear or side facade REPLACE DOOR (NEW) or MODIFY DOOR ADDITIONS & NEW CONSTRUCTION ROOFTOP ADDITION (check all that apply) : Mechanical Equipment, Stair or Elevator Bulkhead Occupiable Solar REAR YARD ADDITION (check all that apply): Deck Occupiable New Building STOREFRONTS INFILLS LIGHTING SIGNAGE AWNINGS SECURITY GATE EXCAVATIONS, SIDEWALKS AND SITEWORK EXCAVATION (check all that apply): Underpinning No Underpinning SIDEWALK PAVING (check all that apply): Concrete Stone Tree Pit SUBSURFACE UTILITIES (check all that apply) : Residential Other STREET PAVING/STREET BEDWORK OTHER TEMPORARY INSTALLATIONS: Sign Other NEW UNENCLOSED SIDEWALK CAF311 SIDEWALK CAF311 LICENSE LEGALIZE OR CORRECT LPC VIOLATION FENCES AND GATES BARRIER FREE ACCESS (ADA) OTHER (Describe): III.ADDITIONAL INFO RMATION Are you filing to correct or legalize work done without an LPC permit? NO YES If Yes , Warning Letter/NOV#: Are you filing for a signoff or to amend a permit? NO YES If Yes , Docket#: Are you applying to any of the following? NO Dept. Of Buildings City Planning Board of Standards and Appeals Is there a facade easement on the property? NO YES (please provide contact information for easement holder) American LegalNet, Inc. www.FormsWorkFlow.com 2 of 2 Rev. 10/17 IV.ATTACH MATERIALS NEEDED TO COMPLETE THE APPLICATION Descriptive m a terials will usually have t o be submitted to complete the application. Required materials include documentation that explains the existing and proposed conditions, and clearly illustrates how the proposed work does or does not meet LPC Rules. LPC Rules and guides are available on the website: www.nyc.gov/landmarks . Depending on the type of work proposed these materials may include drawings, photographs, photo montages, material samples and written specificat i ons. For a complete list of materials required fo r the most common work types, please refer to the Permit Application Guide as you complete the application: www.nyc.gov/html/lpc/downloads/pdf/pubs/AppGuideCompleteVersion.pdf . An application that includes all of the required materials can often be expedited. Incomplete submissions will cause delays. This application will not be deemed complete until it is s o certified by the landmarks preservation commission. You may contact the LPC if you need information about the application process, details about the types of drawings or other materials that may be required, or for general guidance: T el : (212) 669 - 7817 / E - mail : info@lpc.nyc.gov . An application may be completed by the owner, tenant, lessee, co - op shareholder, architect, engineer, contractor, or other individual or firm. Please list all relevant contacts below, and check the primary contact. V.CONTACT INFORMATION (please check off Primary Contact) TENANT/LESSE/CO - OP SHAREHOLDER PRIMARY CONTACT Name: Company/Corporation/Organization: Address: City & State: Zip: Phone: E - mail: ARCHITECT/ENGINEER/C ONTRACTOR (IF APPLIC ABLE ) PRIMARY CONTACT Name: Company/Corporation/Organization: Address: City & State: Zip: Phone: E - mail: PERSON FILING APPLICATION (E.G., EXPEDITOR, ATTORNEY, MANAGING AGENT) PRIMARY CONTACT Name: Company/Corporation/Organization: Address: City & State: Zip: Phone: E - mail: I am the owner of the above - op Board or Condominium Association. An officer of the Co - op Board or Condominium Association must sign this application. I am familiar with th e work proposed to be carried out on my property and give my permission for this application to be filed. The information enter ed is correct and complete, to the best of my knowledge. IMPORTANT: The managing agent of a cooperative or condominium associat ion must be an officer of the board to sign this application NAME TITLE (if applicable) COMPANY, CORPORATION, OR ORGANIZATION (if applicable) MAILING ADDRESS CITY, STATE, ZIP CODE PHONE E - MAIL SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE American LegalNet, Inc. www.FormsWorkFlow.com