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1 <br />Application <br />-FOR - <br />Certificate of Appropriateness <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 /l*ndex.htm <br />p: 574- 235 -9798 f: 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY> » » >DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX « « «O / FFICE USE ONLY <br />Date Received: l x tlLet A e- ` o2D /j Application Number: <1 i <br />Past Reviews: ©�S (Date of Last Review) a o�dC� p ❑ NO <br />v <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />j ❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />A-5 A a t,-- ,7-4 !3 <br />Local Historic District (Naive) � (,!'Lzry,u <br />❑ National Register District (Name) f / <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) • <br />Address of Property for proposed work: 1 0 G W Q {1 P 1 v J 1i L16 6 (5 <br />(� <br />(Street Number treetName ip <br />— City— ZCode) <br />Name of Property Owner(s): R 0li (c r o t I _ o u ( (C M Q R1 n Phone #: 5 - 7 1 0 <br />Address of Property Owner(s): �U (moo y /� 1 5t A) <br />Q n ( (Street Number Street Name — City — Zip Code) <br />Name of Contractor(s): r G t /" 1 yVl n✓J Phone #: <br />Contract Company Name: 41 u <br />Address of Contract Company: �y O n B OLP h 0 yC�a� u S IJ 16 <br />(Street Number— Street Name — City —Zip Code) <br />Current Use of Building: 511 16M 11 y �n MP <br />(Single Family— AViulti- Family — Commercial— Government Industrial — Vacant —etc.) <br />Type of Building Construction: p a ud ri ive <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: On I <br />M ltd e at <br />1 N l <br />k , 3,AtC- <br />I� ,et P i 6 A n o (P(x — o/ffrn o n <br />A�(re Nr 0 -- 6efWer. -AI e <br />lb rot lY) <br />(1a <br />o,,J �aleqe (7c) <br />(..) e Ae i fi ge f ee, o,,J r -d <br />A f "'ea <br />Owner /Contractor Fax #: e-mail: Q f h tNl d a t n e J ,!Y1 d t t. ('3 M <br />(Staff will correspond with only one designee) <br />X r" J17 /� and/or X <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />