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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/SJCHPTndex.htm <br />p: 574-235-9798 P. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE Oft USE ONLY <br />Date Received: IS Application Number: CIO/ W1. — D.3fs fl <br />Past Reviews: YES (bars of Isar Review)�j f ❑ NO ,� . <br />Staff Approval authorized by: �� Jam^ Title: Adm'' <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) lh� <br />❑ National Landmark ❑ National Register District (Nmee) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) � / 6D � 6cu So b �t l too Address of Property for proposed work:'T-44'3-vut 1 CO too <br />(Street Number- Street Name--City-Zip Cade) <br />Name of Property Owner( s): L A-" �- t Phone #:�— <br />Address of Property Owner(s): 4.55 <br />(Street Number- Street Name--City-Zip Code) <br />Name of Contractor(s): V A 1V%.eU RCC>F) A S { n Phone #: <br />Contract Company Name: <br />Address of Contract Company: 4�"7 "7 Co ' %5ikA-w 410+1 t i1� to <br />(Street Number -Street Name--City--Zip Code) <br />Current Use of Building: `1 1 a I CC' C- �'>kv� i 4A <br />(Single Family-Multi-Family--Commercial--Government-Industrial-Vacant-etc.) <br />Type of Building Construction: I--3 t7 -g '-tial F <br />(Wood Frame Brick -Stone -,Steel -Concrete --Other) <br />Proposed Work: 'WIn-Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />Owner/Contractor Fax #: ��� �i e-mail: <br />(Staff will correspond with only one designee) <br />x and/or <br />Signature of Owner <br />X��'�-` <br />Signature of Contractor <br />