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<br /> EXHIBIT C <br /> ENVIRONMENTAL REVIEW FOR <br /> NORTH PENINSULA NEIGHBORHOOD SERVICES CENTER <br /> HOUSING REVIT ALIZA TION PROGRAM <br /> Date: <br /> A. This is to request an Environmental review for a proposed project at the following address: <br /> B. This address is a ( )Single family home ( ) An apartment _Age of bldg. if known <br /> C. The improvements to be made to this home/apartment are: ( ) interior* ( ) exterior* <br /> NOTE: If both interior and exterior improvements are proposed, check both boxes and identify <br /> which improvements are exterior. For exterior improvements to be made to a building which is <br /> at least 50 years old, please provide a site plan showing the location and extent of the <br /> improvements to the building, a work write-up order and/or plans and specifications of the <br /> improvements. <br /> *Interior means the inside of a home, or an apartment. Exterior means the outside of a home or <br /> a multifamily building. Improvements to be made outside an apartment, but inside a multifamily <br /> family building (such as in hallways, lobbies or stairways) are also considered "exterior" for this <br /> purpose. <br /> D. The improvements will consist of the installation or construction of: <br /> ( ) Grab bars ( ) Emergency alert system <br /> ( ) Wooden banister ( ) Smoke detectors <br /> ( ) Mental handrail ( ) Non-skid surfaces <br /> ( ) Prefabricated ramp ( ) Dead bolts <br /> ( ) Wooden ramp ( ) Door bell <br /> ( ) Door knobs ( ) Window latches <br /> ( ) Hinges ( ) Door peepholes <br /> ( ) Bathroom or kitchen faucet ( ) Electronic security systems <br /> ( ) Hand-held shower head ( ) Platform <br /> ( ) Door bell ( ) Trapeze <br /> Other (Please identify): <br /> From: North Peninsula Neighborhood Services Center <br /> Contact person and telephone: <br />