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Application <br />FOR - <br />Certificate <br />' OR - <br />O <br />Cerii�ctrte ofApprapria%txess <br />HISTORIC PRESERVATION CO:1'I14IISSION sg cgz <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://, vww.stjosephcountyindiana.coin/departments/SJCHPftndex.htm <br />p: 574-235-9748 f 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />.,. - ..,........... .,...,., ......- <br />OFFICE USEONLY. »»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS ROX-OFFICE USE ONLY <br />Date Received: Application Number-. <br />Past Reviews: YES (DateoJtos NeVieW) � NO <br />Staff Approval suthoriTtd by: Title: <br />Historic Preservation Commission Review Date: <br />Local Landmark Local historic District pvsmr) <br />National Landmark National Register District (.-name) <br />Certificate of Appropriateness: <br />Denied EJ Tabled Sent To Committee Approved and issued: El <br />(Please Print) - <br />Address of Property for proposed work:` <br />(Street Number=— Street Name--City—Zip Code) <br />Name of Property ' ` <br />Owners • -L apt{ ` V . � U, � + � Phone #: �7� �{ � 7 � ' `� � <br />>r <br />Address of Property Owner(s): a a.rv_�_j din Al ;e_,,d 4th -0 1 ' ��` ` ` �' ' • "�' <br />(Street Number— Street Name--City—Zip Code) <br />Name ofContractor(s): i �l, <br />Contract Company Name: -f c;! ) <br />Address of Contract Company: 77 i> <br />Phone #: <br />/ r J (Street yNumber—Street Name—City--Zip Code) <br />Current Use of Building: :7kC) LP i { G " f ( sd "- ii�'�d - 041 1-D (fit' JMW. t>A l C <br />(Single Family-,ifu4i-Family—Commercial—Gotivmment—Industrial—Vacant—etc.): <br />Type of Building Construction: V\.bo `� (- `t A W). f? - <br />'(Wood Franre--•Brick—Stone--Steel-.-Concrete--Other) <br />Proposed Work: Q In -Kind ❑ Landscape EfNew Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: tAAVV1t \I44(e,c,J 0 { R�2 4?� W ��t� tAta -4 � 1,�s 4s U <br />S3it Ao W'9-7" J to (va i e t,:e.� - zA,_ rt r`44 ri { tt t Rt t.I,po(S . s'a111 VoAw W 040j <br />•if �NSitJ=N� f.-I4i1� c si t� i r �£.fi��,� ��7 t4 �'%�`.�'iS4.-t\ � - ) <br />Owner/Contractor Fax #: <br />(.Str will correspond �sith only one designee) <br />X <br />Sign ure tr v� <br />e-mail: <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />