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2.  

   City of Anoka

   Historical Plaque Application Form

   Planning Department

   2015 First Avenue

   Anoka, Minnesota 55303

   763-576-2728

4. Applicant Information

6. Date Submitted*
   Date Submitted
8. Address
10. City
11. State
12. Zip Code
14. First Name
15. Last Name
17. Phone Number
19. Email Address

21. Building Information (If known)

23. What year was the building built?
    What year was the building built?
25. 2. Exterior construction material (brick, stone, stucco, siding, wood shingle, etc.)

    List any unique exterior architectural feature(s) as well.

27. Supporting Documentation

    Please attach the following information (If available):

29. A. Copy of Abstract

    Attach an abstract of the chronological and historical development of the property.

31. B. Alterations

    List any known changes or modifications made to the property throughout its history

33. C. Drawings/Photos

    Provide any copies of the architectural drawings available along with photos either current or past.

35. D. Additional Information

    Provide any additional information that supports the application. This may include letters, oral histories, newspaper/magazine articles, etc.

37. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
39. Electronic Signature
41. Date of signature
    Date of signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field