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if <br />Application <br />FOR <br />Certi <br />JCate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S Lafayette Blvd qmqf, Be n d , IXT 4440 I <br />http://wu <br />p: 574-235-9798 f* 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE VSEOXLY>>>>>>P0 NOT CO %I PITTF ANY ENTRIES CONTA INTED J USE ONLY <br />Date Received: Z_ I Z_ <br />Application Number: I—JI2 — Z) � 2— 4- <br />Past Reviews: ❑ VIES (Dakefuaseview) ❑ NO <br />Staff Approval authorized by: <br />Title: <br />historic Preservation Commission Review Date: <br />17-1 <br />AJ Local Landmark <br />El Local Historic District (xow) J47 e", <br />❑ National Landmark <br />❑ National Register District (ivamt) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />❑ Sent To Committee Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 1 30 '(X <br />(Street number— Street Name­CityL.-Zip Code) <br />Name of Prop" Owner(s). t Phone 0: 7 <br />Address of Property Owner(s): ?3 <br />(Street Number— Street name— City- --Zip Code) <br />Name of Contractor(s): 6"" ,is �"Icl <br />Phone4; 7zl 7 <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Al'umher— SirceiJNamc­-City--Zip Code) <br />Current Use of Building: d <br />(Single Family—Afulti-Family— Governtnent—Indtatrial-- Vacant--etc.) <br />Type of Building Construction: i U — "2" <br />OVood Frame --- Brick— Slone -- 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: � <br />ij t"l <br />Owner/Contractor Fax #: <br />(Staffivill corospond with only oiq designee) A <br />x I A ' <br />'I <br />N"-1 <br />Sign I lure of Owner <br />e n t I <br />and/or X <br />Signature of Contractor <br />