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11 <br />r <br />Application <br />. F, \\ t�✓ � <br />FOR - <br />Certificate ofAppropriateness <br />Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />• 1sa5 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574=235-9798 f. 574-235=9578 e: SBSJCHPCQco.stjoseph.in.us <br />OFFICE USE ONLi'yam» 0 NOT C OMPT,F.TF:ENTRIES CONTAINEW THIQ AQX«« OFFICE USE O <br />NLY <br />Date Received: a 14104,14 -Application Number: <br />Past Reviews: ❑ YES (Date ofLaMReWew) WNO <br />Staff Approval authorized by: / ,sl` Title: <br />Historic preservation Commission Review Date: (/ <br />❑ Local Landmark Local Historic District (m me) 1? � <br />❑ National Landmark ❑ National RegisterDistrict (Womr) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee roved and issued: <br />(Please Print) - 5o "ij! l v,Address of Property for proposed work: '7 G�A �� <br />r <br />(Street Number- Street Name--City-Zip Code) <br />Name of Property Owner(s): /'% (� t`f t '!'/i%C it' Phone #: &-7 y"� �!' 2'1�e <br />Address of Property Owners}: Ox irj �'�% y if B�s� p, 1-4/ <br />(Street Number --Street Name- City -Zip Code) <br />Name of Contractor(s): /i%i G h`� L /e -a 57r*fC Phone #: S 7�e_ 27y_ 232s_ <br />_ <br />Contract Company Name: 776 tZ C v S -TG /q we <br />Address of Contract Company: 4f 2- q0 /77 /47711" 7-R 4 / e, /3'I <br />(Street Number- Street Name -City -Zip Corse) <br />Current Use of Building: /17 U C 77 - F•f3r�.�t' . <br />(Single Family-Multi-Family-Commercial-Gotivrnment-Industrial-Vacant-etc.) <br />Woo p fR*Aj 6 <br />Type of Building Construction: <br />(Wood Frame -Brick -Stone -Steel -Concrete -Other) <br />Proposed Work: ❑ In -Kind <br />(more than one bur may be checked) <br />Description of Proposed Work: <br />❑ Landscape ❑ New ® Replacement (not in-kind) ❑ Demolition <br />AC -e( -4C1--' Roo/-- C',49162 -/c' 3- rAR <br />l <br />Owner/Contractor Fax#: e-mail:_ 4er - �u5 iou� 4e 0Vr'LAXi y , ne_. <br />(Staff will cor spo wi ly one designee) <br />X �-�[-�r.--t-C.,�.-�,.n----� and/or X <br />Signature of wner .tri t g6 AfC..5•E f< Signature of Contractor <br />R (6 ff� d�' -APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE--- <br />