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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />1�6 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http:/ www.sgosephr.ounWkdhmr.om/depmtmenbAJCHPrmdex.htm <br />p: 574235-9798 f.574-235-9578 e: SBSJCHPC@co.st josej?h.hLus <br />OFF" MONLri»>» «c«<OFFICSW ONLY <br />Date Received: 410. 12, Application Number. <br />PastReviews: ® YES. <br />(0. 0fLi R k.) ❑ NO 1 <br />Staff Approval aathoriud by: l • � ��.� Title: A(Z91 q -k4 I �, <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of App ro riateness: <br />LJ Dented ❑Tabled <br />Local Historic District pv.W <br />❑ NationalReSisterDlsMctpv.N <br />❑ Seat To Committeejai Approved and issued: • Ll 1. <br />(Please Print) <br />Address of Property for proposed work. <br />%%0 sr ./056 Pio 0V rR V 4Z4 <br />���. 410/ <br />(Street Number--Sdret Name—City—Zip Code) <br />Name of Property Owner(a): Jit %!_ G op C 446TZ-7-LE� Phone* J N 2,?, oZr13O <br />Address of Property Owner(s): %/1 ? Af Sr. -G�i <br />(Street Number—Street Name—City—Zip Code) <br />Name of Contractor(:): ' oawE/LS <br />Contract Company Name: <br />Address of Contract Company: <br />Phone #: <br />Ovet Number -Street Name--City—Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commercial—Gamment—In Woia�—Pacm —etr-) <br />Type of Building Construction: �!2 W l E <br />(Wood Frome—Brick—Stone—Steel--Concrete—Other) <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: &R4 i2 L-1) 44A-&)4 ✓. -&t)N7- vreS u Cv.,vGc-Cry= R Owner/Contractor Fax M J e-mail: <br />(Staftill correspond itis onlyone designee) j r� 1 <br />X �� . _,_ <br />5 <br />