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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 Blvd., South Bend, IN 46601 <br />. httpl/www.stjosephcountyindiana,com/departments/SJCHP/mdex.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.it-!iosc?hJn.us <br />OFFICE UN OONLP>»»>DO NOT IbMP .1e77r Ny .NTRIFR l ONTAINED IN THIS BOX«««pF'FI(� (!SB' ONLY <br />Date Received: /* (A2,jez .ZD/- Application Number. /a <br />U <br />Past Reviews: ' YES (Dd qfL WRe*w) ❑ NO <br />Staff Approval authorized by: -,r, Title: <br />Historic Preservation Commission Review Date: <br />❑ Load Landmark 0 Local Historic District pvswt) G- ev,47 e— <br />❑National Landmark <br />111National Register District pv=4 `/ <br />Certificate ofAppro riateness: <br />U Denied ❑ Tabled ❑ Sent To Committee pproved and issued: <br />(Please Print) l <br />Address of Property for proposed work: ty <br />/(Street Number- S1ree Name- City -Zip Code) <br />tame of Property Owner(s): � �. 1G Ae y Phone #: <br />Address of Property Owner(s): <br />(Street Number- it eet J name-CIry,,--Zip Code) <br />Name of Contractor(s): d d %( L/-.() /! J %'�,ej,�� �Sr o•.� Phone #: -As-9, S!J <br />Contract Company Name: <br />Address of Contract Company: O U ��% �k',� /Qr%)f Lj4 w,. k <br />/ <br />(Street Number- Street Name- 01y -Zip Code) <br />Current Use of Building: r�r (u �G r":,/y <br />(Single Family-/Muli1 Family -C fmmercial-Government-Industrlal--Vacant-eta) <br />Type of Building Construction: Gti a r) �/t F0.4 M.P <br />'(WoodFrame-Brick-Slone-Steel-Concrete-Other) <br />Proposed Work: 13In-Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind ❑ Demolition , <br />(more than one box may be checked <br />Description of Pd Wor : i' T s- 'i^ g- , ot,�, i ,, <br />owner/Contractor Fax #: e-mail: <br />=ta„ W111 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 />