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Application <br />-FOR- <br />Certificate 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.st oscphcounqindiana.com/dcpartinents/SJCBPfmdexhtm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@,co.st joseph.in us <br />OFFICE USE ONLYy»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: <br />Past Reviews: ❑ Y98 (Datt of Last ReW-) <br />Staff Approval authorized by: <br />Application Number: — <br />❑ NO <br />Tide: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ❑ Local Historic District (Name <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ElSentTo Committee E]Approvedand issued: <br />Please Print) l , p (� e ` i <br />—Address of Property for proposed work: 3 0LI t- (] O NI V VC J" J�� M �l �l �0 I �� <br />(Street Number_ StreetName---City—Zip Code) <br />- - - -y ' <br />- Name of Property Owner(s): -- V�`u IS -.b lq�, _ - f av J5------ -- - -- - Phone M �� q- S I '1iits " T I l `18 - --w <br />- <br />Address of Property Owner(s): <br />(Street Number— Street Name--City-=-Zip Code) <br />Name of Contractor(s): �C1W� Phone #: SSW" aq 7 ' q709 <br />Contract Company Name: , <br />Address of Contract Company: <br />(Street Number—StreetNtmre—City—Zip Code) <br />Current Use of Building: �' t <br />(S' gle Fami4—Mu1tfqF mnity--Commercial--Gover mient—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frcmte—Brick--Stone—Steel—Concrete Olher) <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: <br />R110 V <br />Owner/Contractor Fax #: <br />(Staff w' 1 corn pond w' only one designee) <br />X <br />Signature of Owner <br />e-mail: <br />and/or X <br />Signature of Contractor <br />