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'Ail <br />Application <br />-FOR- <br />Certificate <br />FOR -Cert ficate o, f Appropriateness <br />HISTORIC PRESERVATION COMMISSION coh <br />of SOUTH BEND & ST, JOSEPH COUNTY <br />125 S. Lafayette Blvd, South Bend, 1N 46501 <br />htip:1/www.st osephcountyindianacom/deparhments/SJCHI'!index-htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE1ONEY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE MONEY <br />Date Received: Y 1 l �O Application Number: 101L, — �y <br />Past Reviews: ❑ YES (AW II LRarx i—) ❑ NO <br />Staff Approval authorized by: Title: <br />- Historic Preservation Commission Review Date: <br />❑ Local Landmark Ln <br />Local Historic District (Name) Y <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />❑ National Register District (N) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: _�) ,1 v �` -1--i �i r"i a"�%� 1�i� J �- N , t-(l� �o L) <br />(StreetNumber— StreetName—City—Zip Code) <br />Name of Property Owner(s): , ` IP P I . i M ,: k Phone #: 519 — CTC, -3 - •"J) � <br />Address of Property Owner(s): 53 3 Til`, 0P__ b 6 C) L <br />. (Street Number— Street Name—tsity—Zip Code) <br />Name of Contractor(s): nt (�' Phone #: % - �/ - 71.3 <br />Contract Company Name: <br />Address of Contract Company: <br />(StreetNumber— Street Name—City—Zip Code) <br />Current Use of Building:rasq <br />(Single Family—MultiFamily—Commercial--Gat ermnent—Industrial—Vacant—etc.) <br />Type of Building Construction: X -) =G 0 1) <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed York: ❑ In -Kind ❑ Landscape Q New ❑ Replacement (not hi kind) ❑ Demolition <br />(more thorn one box may be checked) <br />Description of Proposed Work:�c3Lis� ftp � 'S iii j G rn m,- i , RijtI, )b\;', LA >\} <br />I `'A / i 91�91�1 ��. �cii%✓ :. SLC f �t7Lt�Z/ <br />contractor Fax N: e-mail: Co-M <br />(Staff will correspond'Vill, Only Orfe Ifesignee) <br />4 <br />and/or X <br />Signature of Owner f Signature of Contractor <br />