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Application <br />-FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />httPJ/ www. stjosePheountyindiana- com/departments/SiCHP /index.htm <br />p: 574 - 235 -9798 f. 574 -235 -9578 e: SBSJCHPC(a, co.st- josejph.in.us <br />is L J <br />OFFICE USE ONLri » » > DO NOT COMPLETE ANY FNTRrxc rnNT — NED IN THIS BOX «« «OFFICE USEONLY <br />Date Received: <br />"Y C4 ftZ <br />Application Number: ogd /cZ <br />Past Reviews: <br />YES (nare oflaifLevlew) <br />3� <br />v <br />❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: 16 A,d,E .20 / Z <br />El Local Landmark 01,10 cai Historic District (Nave) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appro riateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />(Street NOkber— Street Name — City —Zip Code) <br />Name of Property Owner(s): &y}7 & & Phone #: <br />Address of Property Owner(s): A10 6 rte- R - n So /7 6 <br />(Street Number— Street Name — City —Zip Code) <br />Name of Contractor(s): A11A Phone #: <br />Contract Company Name: 4Z UV 'Q- - <br />Address of Contract Company: <br />(' ,C (Street Number— Street Name — City —Zip Code) <br />Current Use of Building: J /A✓ e k / In <br />(Single Family.Multi - Family -- Commercial —Government Industrial — Vacant —etc.) <br />Type of Building Construction: 1 4/6 D a - m <br />(Wood Frame — Brick — Stone— Steel— Concrete —Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ® Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked //�� / / <br />Description of Proposed Work: /1/h Al Cr 11 p 4 /+/_; .4.Z4, 4 �� e -� e / � � / .e . e P_ <br />Owner /Contractor Fax #: <br />(Staff will correspond with only one designee) <br />e -mail: <br />X and/or X <br />Signature of Owner Signature of Contractor <br />