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Se p. 10. 2012 11:15AM <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COM1YiISSION <br />of SOU7"II VM & f. JOSEPH COUNTY <br />125S Lafayette Blvd., South Bend, IN 46601 <br />http:/Aww.sgv*cphcounVkdian&oom/depaMentwWCWmdex.htm <br />p: 574-235-9798 i 574235-9578 e: SBSjCBPC@,;a.s*ejoseph.in.us <br />I I ,I ., 1 n II WL -611 <br />OFFICE USE ONLi ��nOa- xrnr ICP.MMETE W RN'MFA C(MATWID IN TMA 1 M,-A,e,*<OFFICE USE ONLY <br />No.9924 P. 1/1 <br />Date Received: <br />PastReviewst ❑YES (DaraarrmrRenew) <br />Staff Approval authorised by. <br />Application Number: o?D/o2 - e 9 / O <br />❑ NO <br />T -I <br />i <br />Historic Preservation Commission P.eview Date: <br />❑ . Local Landmark❑v'focal historic District pVam�J oar % ...� <br />❑ National Landmark Er"National Register District tNamo <br />Certificate of Appropriateness: .�..� r% _ ,,r49 /� <br />_ ❑ Denied E]u Tabled ❑ Sent To Committee ❑ ApV ed sod lM$d: /0 . C <br />._•'•.+••linuntil...u..... lni,ii .n 6...0 e.iltl uduii6ilf..im unil ■ I d <br />(Please .Print) 2 <br />Address of Property for proposedwori:: 30H (tyulVC. _�t�. �lV1� ���0to_ <br />w 11 (Street Arumber— Street Nmxe—pity--Zip Code) <br />At II ff <br />Name ofProperty Owner(s): <br />QN�1 V% cxA(�Q1,.Y� �o (lt Phone #a `1' q - I <br />Address of Property Owner(s): <br />(Street Number ShvetName--Ci0ZipCode)�/ <br />Name ofContractor(s): �/P �1t1 h Phone 9: Jt +"pQ?- q:�(D(Q <br />Contract Company Name: sn . <br />Address of Contract Company: " v <br />(Street Number_— Street Name—City—Zip Cade) <br />Current Use of Building: <br />Type of Building Construction: NAA <br />(Wood Frame—Brick—Stone•-41eel-Zor:mte-0dher) <br />Proposed Work: ❑ In -Kind Lwdscape ❑ New ❑ Fxpla cnt (not to W) ❑ Demolition <br />(more than one box may be check4 <br />Description ofI'mposed Work: I(Vl � d (� t^Id� F c"� <br />N � <br />Owner/Contractor Fax #s e-mail: <br />(Staff w' l cvrr pond w only one designee) <br />and/or X <br />X - <br />Signature of Owner Signature of Contractor <br />