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�� +•���� .O - - FOR - <br />ert ficate ofAppropriateness r <br />HISTORIC PRESERVATION COMMISSION 0 o <br />• .1865 " of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Benda IN 46601 <br />http://www.stjosephcountyindian&com/departments/SJCHP/index.htm <br />p: 574-235-9798 f 574-235-9575 e: SWURC@co.st-joseph.in-us <br />_' OMC -r USEOmYis»>>RU. �MPLM ANY FMMIFS CQM r,�], ,,�N TIiIMM--cr«OMCE USEONLY <br />Date Received: Application Number. cx�",0fo2 <br />Past Reviews: YES (DWe of Last xesdew) % � y'�- f •' • ❑ NO <br />Staff Approval authorized by: Title: <br />historic Preservation Commission Review Date: <br />Local Landmark <br />131"Local Historic District (same) �� a <br />❑ National Landmark ❑ National Register District (Nome) <br />Certificate ofAppro riateness: <br />Denied - ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />.........„...„ a <br />(Please Print) <br />Address of Property for proposed work:�� <br />(Street Number --Street Name--City—Zip Code) <br />Name of Property Owner(s): I %f i/? W #” -51 alt Phone #: C ""` �41e.! : <br />Address of Property Owner(s): :5—r'; It �7" ®111�'i �it •'(�l� �� <br />(SYreet Numbers?— Street Name--City—Zip Corte) <br />Name of Contractor(s): �-� /`� / .-' .. _ Phone #: ;?2) <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Fami Multi-Family—Commercial—Government—tndustrlal—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—SteeF--Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -R4 ❑ Demolition <br />(more than One box may be checkerp <br />Description ofP posed Work: /i�rri�ti, '/�X t,i �`ri c tlt�'y� &'tyl " f4 <br />C'!7 Y id;-�'�r(! J>f%r's// CY 1/� rT rZ <br />r /'/7airs <br />Owner/Contractor Fax #: a -in ll: <br />(Stn„ jj"will correspond with only one designee) <br />Xf i7 fl. and/or X <br />Sieidi re oi"Owner Signature of Contractor <br />--APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />