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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.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st joseph.in.us <br />1_ 1 it <br />OFFICE USEONLi"»»»DO NOT COMPLETE ANY ENTRIES CONTAINED <br />�IRI <br />N TS BOX«««/O�FFICE/USE ONLY <br />Date Received: �- Application Number: /�I 2 <br />Past Reviews: YES (namgfzff&xevkw) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Decried ❑ Tabled <br />Title: <br />Local Historic District (Name) Ohm 0(.I— <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print)l, i J <br />Address of Property for proposed work: "� t! el(/C <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): Raen!69 o&2L40 Phone <br />Address of Property Owner(s): 7?q lP % d A -P . Ssov�pp ,,d 7-/• 406 <br />6 <br />(Street Number— Street Name--City—Zip Code) <br />Name of Contractor(s): rti P Phone#: <br />Contract Company Name: <br />Address of Contract Company: <br />j (Street _Number— Street Name---City—Zip Code) <br />Current Use of Building: Vl F t P. )'et�X '1 / IV <br />(Single Family—Multl-Family--Comj��d" ercial--Government Industrial—Vacant—etc.) <br />Type of Building Construction: - <br />(Woad Frame Brick—Stone—Steel--Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one bar may be checked) <br />Description of Proposed Work: &J'A <br />l <br />ivpq V1 ce r- ds <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />and/or X <br />Signature o O er �Signature of Contractor <br />APPLICATION RE <br />