1. Date of Submittal 2. Project Address: 3. Occupant Name: 4. Owner Name and Address: 5. Project Description 6. Applicable Preservation Regulations: (Landmark, Historic District, Others) 7. I, the undersigned do hereby affirm that the above statements are true and correct and I also agree to comply with the provisions of the Cultural Resources Office of the City of St. Louis. The proposed work is authorized by the owner-in-fee and I have authorization to make this application. Address: Telephone Number (Business Hours): E-mail Forward above attachments to SheaK@stlouiscity.com. Kathleen E. Shea, Director Cultural Resources Office