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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.stjosephcountyindiana.com/departments/SJCHP/index.htm . <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USEONLY­­-DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX— ­—OFFICE USE ONLY <br />Date Received: Application Number: 074/oZ — DEQ 5 <br />Past Reviews: ❑ YES (Date of LastBevtew) NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Local Historic District (Name) <br />�ational Register District (Name) <br />Title: �& <br />Jd4,11c, <br />11 Sent To Committee ❑ Approved and issued: S�I�csdt7 c70/Z <br />i <br />(Please Print) /- k Ave1 f &en 1, 'p � 1 <br />Address of Property for proposed work: 3 Ili Pa.�r I� t'] V / �J%� U�1 I I CJS ,J.I,V I l� <br />(Street Number— Street Name--City—Zip Code) <br />Name of Property Owner(s): V CL r i (tai VL' . R i ed i Phone #: , �oC <br />�oi-k Address of PropertyOwner(s): Sib Aje,. Sou+h L]�r►u+ J-lV 46616 <br />jr <br />(Street Wumber— Street Name—City—Zip Code) h r� <br />Name of Contractor(s): M vk Te-ni pj `l' Phone #:dz!f4 ! �n9 - a / ©0 <br />Contract CompanyoN e: ��cQ �5 <br />__^ T <br />Address of Contract Company: a<SA9D Thwcca RO"�, �(V o%eh L + bcI�N q&554 <br />(Street Number— Street Name—Cty—Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—eta) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel--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: 1` p m o V e <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />X'� <br />Signature of Own,�r <br />dare ���c� i-ree <br />e-mail: <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />