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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.stjosephcountyindiana.com/departinents/SJCB`P/index.ht m <br />p: 574-235-9798 £ 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE 0NLY»»»20 NOT 0= E ,, ANY ENTRIES CON UW&—]N THIS B07t««<<OFFICE USE ONLY <br />Date Received: —7-2x'!!!y oW /oP— Application Number: OW1+2 --- 056 *7 <br />Past Reviews: DYES (DWeofLWRevkw) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Title: <br />❑ Local LandmarkL Pr Local Historic District (Name) �,td <br />❑ National Landmark F National Register District (Naw) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled F1 Sent To Committee ❑ Approved and issued: <br />(Please Print)n 46C 4 <br />-�ddress of Property for proposed work: 10917 R t VEIZs i pe- <br />t/ <br />W,, 1 (Streett Number-- Street Name--City-Zip Code) <br />vV <br />Name of Property Owner(s): &1AW v EX,N6, � leATOAA 3)p &'i ZOW Phone #: 574 -261-08Z7 <br />GJL <br />Address of Property Owner(s): SA MG 5J`I �} , 3 , `; (.o $ <br />(Street Number-- Street Name -City --Zip Code) <br />Name ofContractor(s): NIA Phone#: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number-- Street Name -City -Zip Code) <br />Current Use of Building: G A RAG G <br />(Single Family -Multi -Family -Commercial --Government Industrial -Vacant -etc,) <br />Type of Building Construction: W000 PR.AMt <br />(Wood Frame -Brick -Stone -,Steel -Concrete --Other) <br />Proposed Work: ® In -Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: AL:rciZIN& OVEP114eAo poor, Opt=1VIN6 o EXiSi1NG, <br />C Ait.AGlr T. S= -,E- 4TrAc of Q7 r <br />17 <br />Owner/Contractor Fax #: WA <br />(Staff will correspond with only one designee) <br />X L& Wt &k - <br />Signature of Owner <br />e-mail: IZIA00 Emar-e—YARoO F cvtvi <br />and/or X <br />Signature of Contractor <br />