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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 />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 E 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLri»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: %� /mac+-'O/�- Application Number: <br />Past Reviews: ❑ YES (Date ofLast Review) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />-yo <br />Local Historic District (Nww) <br />❑ National Register District (Name) <br />Title:%t4� . <br />❑ Sent To Committee Approved and issued: <br />J <br />(Please Print) Q n f,/ �� f ��j�j l� <br />Address of Property for proposed work: I0I � l` t vefwIte Pr �vb1T '� be' o' , <br />pdjl*e <br />(Stre/et Nuummber— Street Name—City—Zip Code)/Name ofProperty Owner(s): / k lm d- "An"A� Afi M Phone #• S� VC20 ' It �Z <br />Address of Property Owner(s): /m D✓', J 7001'� U&j . r/V 1'6b 16 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): To & dg_e4ml� Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />Type of Building Construction: <br />(Street Number— Street Name—City—Zip Code) <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />(Wood Frame—J ick—Stone—Steel—Concrete-0the <br />Proposed Work: [61n -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: /`ColovAl <br />V. <br />Owner/Contractor Fax #: <br />(Staff wil correspond t my one designee) - <br />X <br />Signature of Owner <br />;44-w A.d <br />e-mail: <br />mA ker- -t It, Gf <br />and/or X <br />Signature of Contractor <br />