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Application <br />-FOR- <br />Certificate ofAppropriateness <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/in'dex.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC(aco.st joseph.in.us <br />■ <br />OFFICE USE 0NLi>»»>I)0 NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFF^^ICE USE ONLY <br />Date Received: ;' Application Number. 4o/.oZ — 4 PZ1,7 <br />Past Reviews: YES (Date ojLarttteview) Z?KAj -a61� ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />7 J"`'4t OZo / 07, <br />❑ Local Landmark <br />/ice (Q <br />�Loeal Historic District (Name) (.. 44416%/ <br />❑ National Landmark <br />ER*National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Number— Street Name-City—Zip Coders) <br />Name of Property Owner(s): �—(4 A1, ^:VnC k Phone 7 --7 <br />Address of Property Owner(s): <br />�jj (Street Number—Street Name��ty—Zrp Code) �7/ _ <br />Name of Contractor(s): C 41bv>^ ; )1--C Phone #:3 to (o " t (. ? � -7 <br />2 �o <br />Contract Company Name: �_f,•'} �• 1��.ct�� c� <br />Address of Contract Company: J J kt C.� "-A &SP,� +met t 71 i LI CO � G S <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />Type of Building Construction: D <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: C\-, -�—e'VI (-0— e-, ,I <br />CGS C -(A- V' (76-y,+ . <br />�Wy.c e <br />J ' A ll �+.►.Iat 1 <br />Owner/Contractor Fax #: &.o p— 7�DeS'L1 C1 2—tt e-mail: P vv)C!' <br />(Staff will correspond with only one designee) S( ���•A J <br />X and/or X UI <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />