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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.stj osephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE��ON'�LY!*>>>>>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: If >•rMyJ4l Z- Application Number: OW /2 — q0 % _ <br />Past Reviews: ❑ YES (DateofLastRevkw) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />❑ NO <br />Title: <br />a! 7V.NAf Boit. <br />Local Historic DIstrict (Name) , 0, <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) /� • <br />Address of Property for proposed work: <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s):1'2 Cti Cd1q R'0CAj yp}Z3C_kC Phone #: a11--76( o - % 4 -7 <br />Address of Property Owner(s): -70 Fooes+ 14 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): _6DPhone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building:q* �`c` s i?e&L, k jcAc�_at nfv b p inn czo . <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: �` JLV,---'L <br />(Wood Frame—Brick—Stone—.Steel—Concrete-0ther) <br />Proposed Work: L/\j In -Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked)) <br />Description of Proposed Work:i 0: �UU1nQ✓ r co �j��O'Vl�_ <br />Z, AT ,%VVN ft wA } "'q �c eh -T_ t Lln• <br />'rib A3.r►�n` .,c,� ��ntzi✓Gcvtt� <br />Awner/Contractor Fax #: a -mail: eVVNC•r UKiShd ? (.A <br />(Staff will correspond with only one designee) <br />X ? i and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />