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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 />httpd/www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />■ 1 -1 <br />OFFICE USE ONLY>»»>p0 NOT COMPLETE ANYNTR <br />EIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: /.1 'i'x_e 201.L Application Number: <br />Past Reviews: <br />EB"YES (Da gfLa&R-kw) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Nance) CL- f <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied E] 11_ 11Sent To Committee 11Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />Name of Property Owner(s): T <br />Address of Property Owner(s):O``(/ C/ <br />0 Q &e <br />(Street Number— Street <br />QName—Cit),—Zip Code)— <br />/7 Phone <br />S T7 U 1- -5 --t--..J G 6 <br />(Street Number—Street Name—City—Zip Code) <br />Name of Contractor(s): ��"�' V1 Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street <br />tNNumber— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family--Commercial--Gover6�*nt Industrial ,Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame Brick—Sto `e—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape El New Replacement (not in-kind E] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work:1 U .(k.v_-. AcY (j) 1 o -d b L,)_� <br />Owner/Contractor Fax #: a -mail: t Ct, V, �l `rt-, iL l -n � 0 v � <br />(Staff w' aawlyne designee) l - - - V <br />X -•- ... and/or X <br />Signature of Owne Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />