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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, IIV 46601 <br />http://www. stj osepheountyindiana.com/departinents/SJCHP/index.htrn <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCH?C@ro.st-joseph.in.us <br />I <br />OFFICE USE ONLI»»»g) NOT COMP -P. ANY NTRIFA ONTAHy D IN THIS BOX«««OFFICE USE ONLY <br />Date Received: I U i In Z Application Number: �— L l 1 1 1) <br />ws: <br />Put RevieYES (aawufL"Rewew)15. � I,b�_p ❑ NO \ <br />Staff Approval authorized by: Q`\ ( , c, - 'v (: ,Z,? A Title: 0, L_\J <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of App riateness: <br />Denied ❑ Tabled <br />® Local Historic District (Nsmd C G(Ap l n l✓ �-�f'�_ <br />❑ National Register District (ivamr) p� <br />ElSentTo Committee El Approved and issued: 1 V , \ C) , Z <br />(Please Print) Q <br />Address of Property for proposed work: U 10 FAQ 4 AJE 5 t,,, 9,A )^/, `f(,(, I V <br />(Street Number` Street Name—City—Zip Code) <br />Name of Property Owner(s): l/io a A 5 r SU S R nl FEZ y Phone #: <br />Address of PropertyOwner(s): 9/0 pktLie- A✓,5 S°'''r­�` 5 /"j `ISG <br />(Street Number—Street Name—City—Zip Code) <br />Name ofContractor(s): &&An1 Poo Ft vLLr C00,6 lj kcu > Phone#: 5-7q-2'1) - 71-6 3 <br />Contract Company Name: <br />W' U <br />Address of Contract Company: `fo5 57- , N- Gt1?e-A-r (.✓. <br />(Street Number-- Street Namelity—Zip Code) <br />Current Use of Building: StNALe fR& . L -j <br />(Single Family—Multi-Family—Commercial- Government—Industrial—Vacant--etc.) <br />Type of Building Construction: F1Z a r, e <br />(WoodFrame—Brick—Stone reel -Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New H Replacement (not in-kind) ❑ Demolition <br />(more than one bar may be checked) n <br />Description of Proposed Work: /� c M 0 vc ANO 4wc.aCer 45,o a c, 5 r , w /e S 3 T-4113 <br />U-.; Th- /);PA erN 5/6,"We— 5(-1/NCTe,-5. iN fi"A 1\ ,QQ <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) .-7� <br />X and/or <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />