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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, TM 46601 <br />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHFC@co.st-joseph.in.us <br />OFFICE USE ON\Li'- »' >DO NOT COMPLETE ANY ENTRIES CONTAINED' <br />I�N.(E-D� IN THIS BOX` <br />Date Received: Dor i «««OFFICE USE ONLY <br />- t t�O\2 - Application Number: Cw �Z— <br />Past Reviews: YES jj(DateofLastRM—) ❑ NO <br />Staff Approval authorized by: -th CA Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />f=1 Local Historic District pvame) CA ve <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and sued: <br />(Please Print) _l -7 d In <br />Address of Property for proposed work: t 11� dJ <br />(Street Number- Street Name -City -Zip Code) <br />Name of Property Owner(s): Phone #: (766 37e, -171C, <br />Address of Property Owner(s): P03 f'o-yZe-5-1— AV. <br />(Street Number- Street Name--City-Zip Code) <br />Name of Contractor(s): 5'Cp/ /✓ 125 Phone #: <br />Contract Company Name: `-t f2 4-::75 <br />Address of Contract Company: Z jG�?wW-NAJ 57` <br />(Street Number- Street Name -City -Zip Code) <br />Current Use of Building: VII-e47L/ i - f✓� -fLf 1 &1-1 <br />(Single Family-Multi-Family-Commercial--Government-Industrial-Vacant-etc.) <br />Type of Building Construction: <br />(Wood Frame Brick--StoneSteel-Concrete-Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -king ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: �Lr2C>Z3 /iJ /77-34 . +y) <br />,�L�Q?" / 7b �C11/cs`7Z J,�i i 77-� Grdl �1jY�q�Q <br />Owner/Contractor Fax #: e-mail: <br />�dhn n�bber, <br />(Staff will correspond with only one designee) <br />X and/or X <br />Signature of Owner Signature of ContraWr <br />-APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />