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�sot3T1�� Application <br />-FOR- <br />Certificate ©f Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />• 1865 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 />joseph.in.us <br />'ii, 1"1'1'1i1111111'I 1I11111II1II Ilillluullll11111 III IIII II 11 1 1 '1,1 II1111111'11111111111 1 'ilii 1I', I ll lunl,lu,u 111011• a m' 11 11111111111111111 , 1060011111MI1,114'1,,1, 11 1 11 11, 1 6,14WI'i"" i1, u1,- 1I <br />OFFICE USE ONLY}»»>PO NOT COMPLEff, ANY ENTRIES f pNTAINED IN THIS IiOX«««OFFICE USE ONLY <br />Date Received: f` �� ATO! °� Application Number: 461Z <br />Past Reviews; [a. -YES (Date aft a 1ttti4I ❑ NO <br />Staff Approval authorized by: (� Title: . <br />v <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of AppZ5Dcnied <br />ateness: <br />❑ Tabled <br />�%ocal historic District evame) ( . <br />❑' National Register District (,,%I <br />❑ Sent To Committee Approved and issued: 1r 4t'Z4012_ <br />tfv <br />(Please Print) <br />Address of Property for proposed work: lr2 .}CSS 1 1 ,rpt tr, 1l�,� St ' J <br />.� (Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): �(A 1��2l . e V\� � i't_XkGtI Phone #: aq k <br />Address of Property Owner(s): 1"1 )fn ,r w� V ►',,Al <br />(Street Number— Street Name—City—Zip Code) <br />Natne of Contractor(s): �' �� �(i t v� /. Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />} (Street Number Street Name---City--Zip Code) <br />Current Use of Building: �t , � ��,� vti� <br />ngle Family--Aflulti- mily—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: 'C` 4" 154 �,n P <br />(JVood Frame—Brick— &one—Steel---Concrete—Other) <br />Proposed Work: In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more titan one box may be checked) <br />Description of Proposed Work: Y"Q 00,c 10, 4'rVCX <br />Owner/Contractor Fax #: I oii1 ' �` - e-mail: ,�v1i( �it�(r1{ t 0,61 a 6Vk <br />(StI will correspond kith only one designee) t ,j <br />1-- I's and/or X <br />Sign Yr e of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />