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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.stjosepheountyindiana.com/departments/SICBPrmdex.htm <br />p: 574-235-9748 f 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USEONLI'}»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««0FF7CE USEONLY <br />Date Received: Application Number: afd <br />Past Reviews: ❑ YES (&teofLwtRe*w) awo <br />Staff Approval authorized by: Title: <br />Historic Preservation- Commission Review Date:-- <br />❑ Local Landmark ErLociRl Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />—({'lease Print) 1 <br />dress of Property for proposed work: b t " C AOU <br />• (Street Number— Street Name--City—Zip Code) <br />Name of PropertyOwner(s): /0_ 'AAAC15'4o Ga n,2A(0, Phone#: <br />Address of Property Owner(s): ?-574 C e- LAM4 A(le o v-ik deIrJ / LICA It, <br />(Street Number— Street Name--City—Zip Code) <br />Name of Contractor(s): �C L Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name--City—Zip Code) <br />Current Use of Building: h'' + 1. CA n i Gy <br />(Single Family—Multi-Famil)--Commercial--Government—Industrial—Vacant—,eta) <br />Type of Building Construction: G`o ° 1 �t1 C <br />(Wood Frame Brick—&on"teel—Concrete—Other) <br />Proposed Work: E]In-Kind❑ Landscape ❑ New ® Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />11 <br />Owner/Contractor Fax Or <br />(Staff will correspond "with only one designee) <br />4".�X _ <br />SiKature of Owner o <br />ie -mail: <br />and/or X <br />Signature of Contractor <br />A( - <br />