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. Y <br />Application <br />-FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMNHSSION. <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, TM 46601 <br />httpJ /www.st osephcountyindiana .com/depattments/SJCBP /index.htm <br />p: 574- 235 -9798 E 574- 235 -9578 e: SBSJCHPC(a co.st- joseph.in:us <br />OFFICE USE ( O � NLYy » » >P <br />Date Received: q 1 `/ V ►' <br />Application Number: Un , - 1 J40 <br />❑ NO <br />Title: <br />USE ONLY <br />Past Reviews: ❑ YES (nauofzwReview) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Nance) <br />F1 National Landmark <br />) <br />National Register District (Nana) <br />Certificate ofAppropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) -.-I <br />Address of Property for proposed work: �(* <br />Name of Property Owner(s): <br />Address of Property Owner(s): <br />.�) CAr <br />o S. <br />treet N tuber= Street Nair <br />e— City —Zip Code) C� 1 <br />t �a Phone #:�d� i� <br />�i o, L_vj &p , ZI <br />(Street Number — Street Name — City—Zip Code) <br />Name of Contractor(s): 30-0 Phone #: <br />Contract Company Name: _OW 4 IS �j <br />Address of Contract Company: <br />(Street Number — Street Name —City —Zip Code) <br />Current Use of Building: --,5 /Z/ 6 �� j)'j / ( V <br />(Single Fami Multi Family— Commei -cial— hernment Industrial —i <br />Type of Building Construction: 6,tf 00 ri -p <br />(Wood Frame Brick— Stone—Ste �— Concrete — Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New Replacement (not in -kind Ix Demolition <br />(more than one box may be checked) n `� <br />Description of Proposed Work: � � /G d a;W 7 .0Ol? R 7?� <br />L ,� opt? . . <br />er /Contractor Fax #: e-mail: <br />taff will correspo d with only A xzuw,� one designee) <br />X and/or X <br />Signatur f Ow r Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />