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Applicaflon <br />-FOR <br />. <br />certyicate ofApprop <br />1111 riateness <br />At <br />HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY tir <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosephcountyindiana.conVdepartments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joscphJn.us <br />OF NOT COMPLEnAMNTR IF SCQNTAME -FICE USE ONL y <br />DjNMijUM <br />Date Received: ll� 4 :, j, Application Number: o A <br />Past Reviews: ❑ YES (Date of L4uRea ❑ NO jj <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ Local Ilistoric District (Name) <br />❑ National Landmark FINational Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied 11 Tabled El Sent To Committee ❑ Approved and issued: <br />...... .. . . ........ . <br />(Please Print) <br />Address of Prop" for proposed work. l Y F V <br />(Street Number— Sireet,&ame---Oty—Zip Code) <br />Name of Property Owner(s): 0 e� f; �j iej, C-) L Phone #: 5 q99 <br />_j <br />Address of Property Owner(s): __ <br />P_? ii Tfi R-6 <br />(Street Number — Street Name—City—Zip Code) <br />Name of Contractor(s): R U- l t' + ( Ll , � SA� U 4', )) Phone <br />Contract Company Name: 2 - 91 -PI 9 Z. - 7 2- - 'i <br />Address of Contract Company; C, C) V Z_ ' 7- 3'� 7 A <br />, V__A I <br />(Street Mumber— Street Name—City--Zip Code) <br />Current Use of Building: S�) y") r: ? IC � " _F_'*1 lv`. I <br />(Single Fil;--A;ul;i-Familp—C&nmercial—Government—Industrial—Yacani—eic, <br />Type of Building Construction: L'6 z"nrk t fi " <br />(IFood Franie—Brick--Sione—Sicel—Concrete—Other) <br />Proposed Work. In-Kind ❑ Landscape ❑ New ❑ Replacement (not in -kind ❑ Demolition <br />(more than one box mopbe checked) <br />Description of Proposed Work: _T:Ec;f` o - 0 <br />rj I ),I e 144 IN I-IVK 66/ &"Co <br />'V1 Pil 04C)l FieN6G <br />Owner/Contractor Fax #: e-mail: F" f Ui i\ <br />(Stqff will correspond with o4fy one (ksignee) <br />X and/or X <br />Sigilaturedflbwner"" Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />