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Official Name of Government
Requesting Certification: ________________________________________
Name of Chief Elected Official: ________________________________________
Address: ________________________________________
________________________________________
Name of Contact Person: ____________________________ Phone: _______
Name of Historic Preservation
Commission: ________________________________________
Name of Historic Preservation
Commission Chairman: ________________________________________
Address (if different than
above): ________________________________________
________________________________________ Phone: __________
Time and Place of
Commission Meetings: ________________________________________