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Application <br />-FOR- <br />Certif tate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette TIN South Bend, 1N 46601 <br />hup://www.stjosephcouatyi &na,com/departments/SJCW index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SWUPC&o.st joseph.in.us <br />OFFICE USE OMPOWIO NOT COMPLETE ANY ENTRIES CONTAINED IN UMMY <br />Date Received: <br />Past Reviews: n - YES (DavefLarRedoo <br />Staff Approval authorized by: <br />Application Number. <br />❑ NO <br />Title: <br />Historic Preservation Commission Review Date: <br />❑Local Landmark ❑ Local Historic District (iV=4 <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate ol'Appmr riateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Aease Print) <br />dress of Property for proposed work: &_&.-moi <br />(�S"et Nunrber—Street Name- City—Zip Code) <br />Name of Property Owner(s): IJ; :t4►+M 1"'Z I� Phone#: <br />Address of Property Owner(s): l l 5 % <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(:): u Phone #: <br />Contract Company Name: a .��"� 1J�-' (d <br />Address of Contract Company: (i E i' L/46+ o 3 <br />(Street Number—Street Name—City—Bp Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commerclal--Government=lndusMai�--Yacant—etc.) <br />S46 j r-• <br />Type of Building Construction: l7 OCA k - 03 ca (Z-- O � J 46 rJ� <br />'(Wood Frame—Brick--Stone—Steel—Concrete=Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New X Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: tA. t.'r c,'o% t 4K 1 12%, <br />t(� C S• w�.�. f� <br />o . 2 (. f <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond one desee) <br />X �:�iand/or X <br />Signature of Owner Signature of Contractor <br />