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Application <br />-FOR- <br />Certi Kate 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/index.httn <br />p: 574-235-9798 E 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS B0X«««pOFF10E USE ONLY <br />Date Received: ad 6"Zq ow%aZ Application Number: CW/ -7 — Vief 04 O <br />N <br />Past Reviews: YES mare ojlast Renew) / 'to O S ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: 1 / L _-")P . aiq/z <br />❑ Local Landmark 191"Local Historic District (Name) SP�`�k'lUt7Gl�lJ <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied11Tabled 11F1 <br />To Committee F1Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: (P o- l L i n c D I n r a S+ J `} h (�. e n rl y %0 <br />`'� (Street Number—Sheet N me-6,)—Zip Code) <br />dame of Property Owner(s): 1b I A A e, ! M Q v\ Phone #: ` -7LI - 3 (40-21141 <br />Address of Property Owner(s): 10 1 (n C1, a r I e s 44 L" i CeO Ir %)�1 Ll I o S Co l <br />(Street Number— Street Name—Cih—Zip Code) <br />Name of Contractor(s): Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: _M f) I •i-, -I!; r" ( <br />(Single Famihv Multi �amil),--Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: W O A Gi vH t. <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ErLandscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: T�h S �a I 1 h [k{Yi fj t:A in r A- vin a <.�e_,' <br />�(1!?' C•j Tyr r,-+ III V%-5 1 J i A'L. � 1 L2 /Sl -� I i�� R/ o ✓ 4 oA <br />T� ni ti. l c t tr1 _ IC��' CA Q %� i'i11� t•� h e- b Lj I f- v :`�'1. `F �"c'tt i- t cQ <br />L� Vvk hP,r , �— <br />Owner/Contractor Fax #: e-mail: <br />to respond ivith only o designee) <br />I&ILZ and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />