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A* <br />FA M-1 M - <br />FOR -II <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />Of SOUTH BEND & ST. JOSEPH COUNMY <br />125 S Lafayette Blvd South Bend, IN 46601 <br />http://www.stjosephcountyindimacom/departmenWSJCHPfindex.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFF10EVS-E0NLY—>>>>D0 NOT COMPITTF, ANY ENTR TV -S, CONMAIINLF1q) TM <br />jjMIMM<<<<<<0FF10E USE ONL V <br />Date Received: Application Number: <br />Past Reviews: YES ❑NO, <br />Staff Approval outboriztd by: L t Title: A'eZ&A, <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (,,vxw) <br />❑ National Landmark ❑ National Register District (Now) <br />Certificate of Appropriateness- <br />❑ Denied ❑Tabled ❑Sent To Committee p roved and issued. <br />B -16p <br />. . .. .............. 11,''I'L I .. ... ... . .. . .. <br />(Please Print) <br />idress of Property for proposed work: <br />.(Street Number --Street 'VOPhone Name--City-Zip Code) <br />j I ;� �' <br />Name of Property owner(s): 'v / r4tI <br />I-Agwq�/' <br />Address of Property Owner(s): <br />elMumber- Street Name--City-Zip Code) <br />Name of Contractor(s): Y-0 1z -c-->-5 <br />Contract Company Name: <br />4V <br />Address of Contract Company: <br />(Street MuCber- Street lVame-City-Zip Code) <br />Current Use of Building: <br />(Single Family--Multi-Family-Commerctal--Goi,-rnment-Industrial-Vacant---ele) <br />Type of Building Construction: <br />(Wood Frame -Brick -Stone -,Steel -Concrete -Other) <br />Proposed Work: gin -Kind ❑ Landscape 11 New 0 Replacement (not in-kind) E] Demolition <br />(more than one box may be chocked) <br />DescriTtion of Proposed Work; 14� -teA f 04 O -V (A Pre- r Y-0 0 <br />'4 <br />II <br />C, vi:k, +�r4v,� VL n ct NO <br />Owner/Contractor Fax M e-mail: <br />(Staff will correspond with only one desigfic-e) <br />X and/or X <br />Signature of Owner Sign <br />pture of ContraZ7 <br />