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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, 1N 46601 <br />httpd/www.stjosepheountyindiana.comidepmtments/SJCBP/index.htm <br />p: 574235-9798 f. 574-235-9578 e: SBSJCHPC(aco.st-joseph.in.us <br />I .. ..JAI R L L <br />OFFICE <br />Date Received: <br />USE ONLY <br />Past Reviews: YES (DW of Lmt Re f.) <br />Staff Approval authorized by: Q21 -P <br />❑ NO <br />Title: (ad <br />Historic Preservation Commission Review Date:(�1! . <br />❑ Local Landmark Local Historic District (N—e):F � <br />❑ National Landmark ❑ Nstioasl Register District pva»Le) <br />Certificate of AppWenled <br />eness: <br />❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) `_ <br />Address of Property for proposed work: , VAI �• y, �At� S ` Y <br />(Street Number-• Street Name—City—Zip Code) <br />Name of Property Owner(s): �� r \ 4\ w � a '..nqPhone #: , �'`� ►� -� <br />Address of Property Owner(s): i �1V r ,q 'FA <br />(StreiNVumber-- Street Name—City—Zip Code) <br />x-14 - 131,- zBoa <br />Name of Contractor(s): r \ OL d i a ��� `2r Phone #: <br />Contract Company Name: !—""'C�' , ► q� <br />r C <br />Address of Contract Company: �� a <br />(Street Number—Street Name--City—Zip Code a l <br />Current Use of Building: • '� <br />(Sin�1e Family—Multi-Family—Cdnmercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: ' ,, r l (,r <br />'(Wood Frame Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind YLandscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked)Q C ` C <br />Description of Proposed Work: ` `� vf�e %1 %.- Q �^ �- �t ��� \\ ¢, o.. �..� �r �.�� ,� Y C <br />%V • 41% �y . ^%& " h\ Y_ \• fin` <br />lks�nt v C `MA �t Q ^ Q \ �\ S �e <br />Q Yee a CJ _•L_J A •c � )0\-. <br />Owner/Contractor Fax #: 91 `z Z 1 -mail: ` `i L� v1 r • moo, -AL p `�. <br />(Staff will. co rr spond with only one designee) <br />X jam: i t� and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />