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Appkafion- <br />-FOR- <br />Certificate OfAppropriateness <br />MSTORICPRESMATIONCOMMISSION <br />'of SOUTH <br />H BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend IN 46601 <br />hup-//www:s�osepheountyindian&wm/departments/SJCHP/indexhtm <br />p.:.574-235-9798 f; 574-235-9579 e:.SBSJCBPC@co.st-josephinus <br />OFFICE USE 0NLY>>­­DO NOT COMPLETE ANY ENTRIES CONTAINED IN TIIIS BOX<<<<<<0MC9 USE MY <br />pateRecelved: 447 Application Number. <br />Past Reviews: EIYES (DWfU#A9vkw) ❑ NO <br />Staff Approval authorized by: Tide: <br />Historic Preservation Commission Review Date. 109 2, <br />E] Local Landmark Local Historic District (No❑ ' <br />VN <br />National Landmark ❑ National Register District (N.,W <br />Certificate of Appropriateness' <br />F] Denied ❑ Tabled 0 Sent To Committee ❑ Approved and Issued: <br />• <br />(Please Print) <br />Address of Property for proposed work- 34q - M�. - --i1prig I +(o �&nJ (4voic, <br />5, �& --xx) <br />(Street Number— e� r— St re e t Ya- m e— Cil) � —Zp Code) <br />Name of Property Owner(s): 4qo�wjcta_ )iII-01— Phone #: r 23 3 -W1 "X <br />Address of Property Owner(s): ?i LA 4 .. 90 Vinu --, ; A e —rj-) <br />(SOmet Numbers Street Name­Qty—Zjp Cod?) 44 61'0 C5 <br />Name of Contractor(s): I,3 <br />Phone #. <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number—Street Name—Cit <br />P—Zip Code) <br />Current Use of Building: vin ( Y'Y1 i 1 L• <br />(Single <br />-,P(Single FA6LMulti-F—amily--CommeM@:-Gov.erninent—Industtial--Vacant--ete.) <br />Type ofBailding Construction: <br />(Wood Frame—Br. <br />Proposed Work. ❑ In -Kind 14 Landscape El New EIRep'lacement (not in-kinio ElDemolition <br />, <br />{more than one box may be checked) <br />Description of Proposed . WA ork: Qe0jacimr.- -el&js �kYV ---I 40VI P Vr_L flN 1 — <br />*,L) -S in. <br />--7---T <br />VA,_A Lo, rZ V) pcjMep A -r, wa If -AA I' _- <br />f;.� X <br />Owner/Contractor Fax #: 0-2 all: I <br />(S ffvi Zondwfth;n,1yone designee) <br />X <br />aid/or X <br />Signa <br />of Owner Signature of -Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />