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Application <br />- FOR - <br />ertifacate ofAppropriateness <br />le `r � ? HISTORIC PRESERVATION COMMISSION <br />-� labs of SOUTH BEND & ST. JOSEPH COUNTY �a ►` <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />hUp://www.stjosephr,ountyindiana.com/departments/SICHP/index.htm <br />p: 574-235-9798 f: 574-235-4578 e: SBSJCHPC@co.st-josephAn.us <br />I 1 11, 110 1,.,411 , <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY FNTRTFS CONTAINt'D IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 'J >'ez :application Number: <br />Past Reviews: ❑ YES (Date o/Lastsmew) ❑ NO <br />Staff Approval authorized by: Title: ,Ctf1.Cx <br />Historic Preservation Commission Review Date: <br />f ' <br />❑ Local Landmark 9 --focal Historic District (.Name) <br />❑ National Landmark ❑ National Register District gvam4 <br />Certificate of appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) l <br />Address of Property for proposed work: I ( t • , • �:4 <br />{Street lvumber—Str e} City—Zip Code 4211 <br />Name of Property Owner(s): { —?.y a.,,.. Phone #: t. �� 3 t 6[ —17TO <br />Address of Property Owner(s): t `u eti �c'4 A—, <br />(Str�/�jeet Number—Street name—C,i(y—Zip Code) <br />Name of Contractor(s):L(L',�I t c..t:<� , Phone #: <br />Contract Company Name: <br />Address of Contract Company: , t, 1."i+� t`S 4?a <br />r ! <br />(Street Number— Street Name—City— 'tp Code) <br />Current Use of Building:'��j�—Xf <br />•(Single Fam`iulti-Family— fonintercial- Gotiernment—Industrial—Vacant—etc.) <br />Type of Building Construction: &a- (�,X'taer <br />(frond Frame—Brick—Sione' Steel—Concretc—Other) <br />Proposed Work: In»Kind ❑ Landscape ❑ Ncw <br />(snore than one box may be checked) <br />Des tion of Proposed Work: r1la r <br />❑ Replacement (not in-kind) ❑ Demolition <br />LL (-s o ue <br />Owner/Contractor Fax #: e-mail: <br />(Staff will rrespond with onl ane, desi r e <br />X,� ,c h. and/or X <br />_ariSignal a of per Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />