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Application <br />-FOR- <br />Certif ieate 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.stiosei)hcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 €: 574-235-9578 e: SBSJCHPC cz,co.st joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 17' 020%I Application Number: — <br />Past Reviews: ' ❑ YES (Date of LastBevkw) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />L' Local Landmark ❑ Local Historic District (,name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled . ❑ Sent To Committee proved and issued: 7" ,'/ <br />(Please Print) <br />Address of Property for proposed work: Is- � �-'C- <br />(Street Number—.Street Name—City—Zip Code) <br />Name of Property Owner(s): ti,..c rt rxs� �'� '= �4►... ��c>� Phone #: <br />Address of Property Owner(s): <br />(Street Number— Street Name—City--Zip Code) <br />Name of Contractor(s): Phone #: �S 7 `1 �S`i ~Gi 7Z:�-: <br />Contract Company Name: ;�, t'� v � � 1, <br />Address of Contract Company: (i • 7 �> , "e- � �`� ��'` '- ' - '� 46 6 � I <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Famil),—Multi-Family--Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—,Ston"teel--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: I i cz:_ K <br />7 <br />Owner/C i ctor F � i q� Z O� -- 0 _Z '7 <br />(Staff wil c rr and it =only one designee) <br />X _ <br />Signature of Owner <br />- <br />e-mail: `-��"t.,c;•� .� 1 G -% -57�c-� <br />and/or X <br />- Signature of Contractor <br />