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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION CO?tnUSSION <br />ofSOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd. South Bend, IN 46601 <br />http: / /www.st josephcounryindiana .com/departinents/SJCHP /ilidex.htiu <br />p: 574 -235 -9798 f 574- 235 -9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE ME aVM>> > »DO NOT COMPLETE ANY EIMMES CONTAINED IN THIS BOX «« «OFFICE ME OAZY <br />Date Received: 3!) .20 Application Number: otd — 9V 10 <br />Past Reviews: ❑ YES (D"efLastiza -kw) O , <br />StaffApproval authorized byt /�'✓ Title. <br />Historic Preservation Commission Review Date: <br />EI /Local Landmark ❑ Local Historic District ¢lm w) <br />❑ National Landmark ❑ National Register District OV=se) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee! ('approved and issued: JO -t0 <br />uu U y <br />{Please Print) ` ,, t <br />Address af Property for proposed work- <br />( Sir eetNtanber- StreetName-- Citg -Zfp Code) <br />Name of Property Owner(s): ln <br />k �Y Iln.gey Phone #: <br />Address of PropertyOwner(s): 5 lD5 as 6 a:0kh &m', K <br />(Street umber- StreetName -Cftp -Zip Code) <br />Name ofCoatractor SQ14, c'�(``1 FI 'I Q 1C-Q- Phone #: <br />ContractCampanyName: , i �}' �'!tN► j �S21 <br />.Address of Contract Company: rl <br />��2 l l e—& % - &nri1 i/v - `T�ul3 <br />tNumber— StreetName -00 —Zip Code) <br />Current Use ofBuilding: > mde. t <br />(StngteFamily— htultf- :amidy— Commercial —C verAment—Industrkd— Vacant —etc.) <br />Tape of Building Construction: <br />(Tirood Frame Brtek Stone — Steel Concrele- -Other) <br />Proposed Work: 6410-Kind ❑ Landscape ❑ New ❑ Replacement (not in -kin) ❑ Demolition <br />{more than one box may be checked) <br />Description of Proposed Work: <br />O►rner /ContmctorF #: cr—lT-2g—i—'5�taq e-mail. <br />(Stafficill co tt one designee) <br />X " and /or X r <br />Signatufa of Osvaer ��,� �,.. Sighature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />