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�SpUTFl Ll� <br /> Application ,A°o��b ss�ioptgro <br /> FOR <br /> Certificate of Appropriateness <br /> HISTORIC PRESERVATION COMMISSION 00 <br /> " 1865 " of SOUTH BEND&ST.JOSEPH COUNTY <br /> 125 S.Lafayette Blvd,., South Bend,IN 46601 <br /> http://�v�viv.stjbsdphpO untyiridiaiia.cdnVdepartments/SJCHP/index.htm <br /> P.:574-235-9798 f:574-235-9578 e:.SBSJCHPC @co.st joseph.in.us <br /> OFFII�CE USE ONLYy»»>DO NOT COMPLETE ANY rg!TRIES CONTAiYED!N THIS IIOX<<<<«OFFICE USEOXI.Y <br /> Date Received: —1 0 Application'Number: A V$O <br /> Past Reviews: VES. (Dnfc.fLasf Rcv1m) ❑ NO <br /> Staff Approval authorized by: Title: <br /> Historic Preservation Commission RevicW Date: 10\ScInA� 1Q <br /> dLocal Landmmark ❑ Local Historic District tName) <br /> ❑ National Landmark ❑ National Register District name) <br /> Certificate of Appropriateness: <br /> ❑ Denied ❑ Tabled ❑ Sent To C6nimittcc ❑Approved and issued: <br /> (Please Print) <br /> Address of Property for proposed woric <br /> (Street Number=Street Nanre—City—Zip Code) <br /> Name of Property Owner(s): G v�� /?` ��Y� Phone#: <br /> Address of Property Owncr(s): I L/ ° 711 51'e• )',"z <br /> ((S Street Number—Street Nanre—Clly--Zip Code) <br /> Name of Contractor(§): �"r�� � v,�y Phone 9: <br /> Contract Company Name: G+�� 5-(-Vk <br /> Address of Contract Cernpauy: 12- r-1 W. 77torwlut 9�L• �el, Y-k-' ;"z,;•�7'/Y deoI — <br /> (Street.N(mber—Street Nanre—City—Zip Code) <br /> Current Use of Building: �GrKM oy`-L ,`Ix <br /> (Single Famil)i—Multi-Fariril y—Coiri»rercial—Governureut—Inditsirial—Vacant—etc.) <br /> Type of Building Construction: /1", K_ <br /> (Wood Frar)ie—Brick—Sione--S7ee1—Concrete—Othet) <br /> Proposed Worla ❑ In-Kind ❑ Landscape ❑ New M Replacemcut(not in-kind) ❑ Demolition <br /> (more than one box may be checked) ,J_ / <br /> Description of Proposed Work: "ZJ i tti '+�oc�� ��•c�. ./�, /� (.— c y�1::.�—`� <br /> S i�"da; +-r� � 1v,tn/�i.•_ �e,�ir��.--+/�- ;r le� � +�.._ �/ � � 7a ��' � <br /> t <br /> Owner/Contractor fax It: a-mail: t/"l„ro c_a,a <br /> (Staff Ivill correspond)vilh 0111ygite designee) <br /> X C and/or <br /> Signature of Owner Signature of Contractor <br /> —APPLICATION REQUIRE,MENTS ARE LISTED ON REVERSE SIDE- <br />