Welcome - Kentucky Heritage Council



Kentucky Heritage Council

410 High Street

Frankfort, KY 40601

(502) 892-3606

vicki.birenberg@

Kentucky Certified Local Government Program Application Form

Date:

Name of Government:

Name & Title of Chief Elected Official:

Staff Contact:

Mailing Address:

Phone Number of Staff Contact:

E-mail Address of Staff Contact:

Name of Preservation Commission/Review Board:

Meeting Time and Place:

Please check each item listed below and attach with completed form.

(1) A copy of the adopted local historic preservation ordinance.

(2) A copy of the Preservation Commission’s rules of procedure or bylaws.

(3) Letter from the chief elected official that requests Certified Local Government status and states that the local government will fulfill and maintain all requirements for certification.

(4) A list of the members of the Commission and terms of office (form attached).

(5) A resumé OR Background Form (attached) for each Commission member.

(6) A copy of the Certificate of Appropriateness application.

(7) A copy of meeting minutes from the previous four (4) Preservation Commission meetings.

(8) A sample notice of a public meeting for the Commission.

(9) Clearly defined map(s) of the boundaries of the district(s) and/or individual landmark sites and a list of the resource inventory.

_______ (10) A copy of the guidelines used to review Certificate of Appropriateness applications.

_______ (11) A resume of the staff liaison to the Preservation Commission, demonstrating professional experience in the administration of historic preservation programs. This role can be fulfilled by planning staff with preservation experience or by contract with a professional historic preservation planner.

Local governments that have not achieved CLG status are not permitted to participate in the annual CLG matching grant program. To apply for the grant, Certified Local Governments must file a separate annual grant application with the Kentucky Heritage Council before the annual deadline. CLGs are subject to all federal and state laws and regulations in connection with the application and use of federal grant monies.

Certified Local Government Application Form (cont.)

Name of Government:

Commission Membership

A concerted, documented effort must be made to identify and appoint at least two commissioners with an educational or professional background related to historic preservation. This includes the professions of historic preservation, architectural history, architecture, history, archaeology, historic preservation planning, or related disciplines, such as American studies, urban planning, American civilization, cultural geography, or anthropology. All members must have a demonstrated interest in historic preservation. If the Preservation Commission is comprised of more than five members, please include information on all members. A resume or Background Information Form (next page) is required for each preservation commissioner.

| |Name & Profession |Expiration of Term |

|1. Chairman | | |

| | | |

|2. Vice Chairman | | |

| | | |

|3. At Large | | |

| | | |

|4. At Large | | |

| | | |

|5. At Large | | |

| | | |

|6. | | |

| | | |

|7. | | |

| | | |

|8. | | |

| | | |

|9. | | |

| | | |

Certified Local Government Application Form (cont.)

Name of Government:

Commissioner Background Information Form

(Please Make Copies and Complete One Form for Each Commission Member)

Commissioner’s Name:

Please give a brief description of your demonstrated special interest, knowledge, or training in the field of historic preservation.

Preservation Training Received & Date of Training (e.g. workshops, conferences, lectures, etc.)

Are you a member of the following? Yes No

|The National Trust for Historic Preservation | | | | |

|National Alliance of Preservation Commissions | | | | |

|Preservation Action | | | | |

|Preservation Kentucky, Inc. | | | | |

|Kentucky Historical Society | | | | |

|Other: | | | | |

|Other: | | | | |

Are you presently or have you ever been a member of any other state or local government board or commission? No Yes

Please list and give dates of terms:

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Updated Dec2020

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