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,r <br />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.sgosephcountyindim&com/departrnents/SJCBPfmdex.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st joseph.in.us <br />OFFICEJU'SE ON�LF>'»-»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USEONLY <br />Date Received:. 7 Application Number. <br />Past Reviews: Li YES (D&.gfLW1..) 311.,4? owo % ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: Y, a/-, <br />❑ Local Landmark Local Historic District tNmW ) <br />❑ National Landmark ❑ National Register Districi pv=4 <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />■ <br />(Please Print) + <br />Address of Property for proposed work: fcL <br />Name ,. (Street Numbe� treet Name—City—Zip Code) <br />Na a of Property Owner(s). 1 Mo., -Phone #- <br />Address of Property Owner(s): , 0 q ��Li�. ICJUL 1�L J—N <br />(Street Number—,4 eet Name—City—Zip Code) <br />Name of Contractor(s): / (_ O— " /9410 xJ2 y%(aZ' (20 .. G'�e� Phone #: <br />Contract Company Name: Cl (3Q. / ,i3 & 16k . <br />Address of Contract Company: 17,00 4 XWO/ Si,' saleso 6;tete <br />I . (Street Number Street Name-CCit—Zip Code) <br />Current Use of Building:tw rn•11 <br />fW ,M- gle Famil inti Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction:`J."iC� <br />(Wood Frame—Brick--Stone—Steel—ConcreteOther) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New . Replacement (not in-kind ❑ Demolition <br />(more than one box may be checked <br />Description of Proposed Work: V�lr(�2X1`�v �� . Y �04UQ.. 1G1t11 I ►'l (S"1�. <br />—k4V\f \KNQ 6jhr \ h R, <br />�l,. )c�Jl��• W c L1 n� <br />QUIZ o ro <br />C A <br />/4 ��wner/Contractor Faa #: o[ ® e-mail:pq�► (T�r�1, C`C�Y✓\ <br />(Stcr� will co espond w <br />ith only one c�esi e) <br />X ,�:he�6� C�J. and/or X <br />Sign re f Owner Signature of Contractor <br />