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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 Heid, IN ArAnl <br />httpd/www.4osephcountyindiana.com/departments/SICHPfuidcx.htm <br />p: 574-235-9798 f: 574235-9578 e: SBSJCHPC@co.st joseph.in.us <br />OFFICE USE ONL Y>»»>DO NOT COMP ETE ANY ENTRIRS ONTAiNFD IN THM BOX«««OFFICE USE ONLY <br />Date Received: � Application Number: -- <br />PastReviews: ❑ YES (MM oftaraew-) ❑ NO <br />Staff Approval authorized by:14 <br />,V <br />Title: _bld�td/ <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (V"4 61r�l Cly <br />❑ National Landmark ❑ National Register District (Naw4 <br />Certificate ofApproriateness: <br />L._! Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued:j�- <br />i <br />(Please Printf <br />Address of Property for proposed work: <br />Name of Property Owner(s): �'l - 121 ' Phone #: .tag ""58 Z(4,ZZ <br />Address of Property Owaer(s): _�+ Z Nov. 4 ^) (; ��d��� �1 �U� ' ° E� `_—•, ( tom ��� �� <br />(Street Number Street Nam�ty—lap Code) <br />Name of Contractor(a): (,)i": i.-. �-n/Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number Street Name--City—Zip Code) <br />Current Use of Building:; -UP-1— <br />- "' 1(�- ✓ r vt {o �r iyl <br />(Single Family—Multi -Family—Commercial-=,Government—Ind iat—t <br />Type of Building Construction; <br />(Wood Frame--Brick—Stone—Steel—Concrete—Other) <br />I <br />Proposed Work: -Kind ndscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(mare than one box W14 checkers) j <br />Description of Proposed Work: . G An .,c: cit �r -1_�' <br />c►,�✓ ..S S t Wv''�ez�. �r� ✓ ��-��,-�Q ria rT? <br />Cn re�t�►✓`5 `�c�,sa.n✓� re(i`r5 cs7-Zu`� <br />Owner/Contractor Fax #: e-mail: CoA �� A Vim?,; 4-5 • ' � 14,, 7 <br />(Staff will correspond with only one designee) <br />X and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />