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F:\Development Services\PLANNING\Design Review & Historic Preservation Board\Puyallup Historic Register App.doc 1 HISTORIC REGISTER APPLICATION This application is to be accompanied by six completed copies of Puyallup’s “Nomination for Inclusion in the Puyallup Register of Historic Places” application. (Office Use Only) CASE NO.: DATE SUBMITTED: STAFF ASSIGNED: 1. APPLICANT: 1.1 Name: 1.2. Agency Name (if applicable): 1.3. Mailing Address: 1.4 Phone (Day Number): 2. OWNER: 2.1 Name: 2.2. Mailing Address: 2.3 Phone (Day Number): 3. LOCATION: 3.1. Assessor's Parcel No.: 3.2. Property Address: 4. CERTIFICATION: I hereby state that I am the applicant listed above, and certify that all information contained above and in exhibits attached hereto is true and correct to the best of my knowledge and belief and is submitted for consideration by the City of Puyallup, pursuant to the provision of the Puyallup Municipal Code. It is understood that the processing of this application may require additional supporting evidence, data or statements. RIGHT OF ENTRY: By signing this application the applicant grants unto the City and its agents the right to enter upon the premises for purpose of conducting all necessary inspection to determine compliance with applicable laws, codes, and regulations during the processing of this application. ---PAGE BREAK--- F:\DEVELOPMENT SERVICES\PLANNING\DESIGN REVIEW & HISTORIC PRESERVATION BOARD\PUYALLUP HISTORIC REGISTER APP.DOC 2 PAYMENT OF FEES: By signing this application, the applicant agrees to pay whatever fees are incurred by Puyallup in the processing of this application, including any accompanying application for special tax valuation for the same property. These fees will be levied prior to the completion of processing this application or that for the special valuation request. INDEMNIFICATION: By signing this application, the applicant agrees to indemnify and hold harmless the City and its officers, agents, and employees or any of them from any and all claims, actions, suits, liability, loss, costs, expenses, and damages of any nature whatsoever, by reason or arising out of any negligent act or omission of the City, its officers, agents, and employees, or any of them, in processing this application or in the administration of the Historic Register Program. Applicant acknowledges that this process does not guarantee or assure a designation as a historic property, and that no cause of action is created and the applicant releases the City from all liability or claims. No cause of action is against the City for its failure to process the application in a timely fashion, make a favorable recommendation on the application, or otherwise manage the process to the benefit of the applicant. Signature of Applicant: Date: Signature of Property Owner: Date: Signature of Agent: Date: