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A pplication <br />-FOR - <br />Cer#ficafe of Appropriateness <br />HISTORIC-PRESERVAT16N COMMISSION <br />of SOUTH BEND & STi JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend,,IN 46601 <br />littp:// w. s'tjosepheowityhidiana .cuuddcvarimruts /SJCHP /index -litin <br />p: <br />$74235 -9798 _ ;, f :574 - 235.9578. a :'SBSJCHPC @co.st josepll.in,us <br />OFFICE USE 0A >-Y — > >DO NOT CO \(PLETE ANY WrRIES CONTA�I�N/E�D LV TkS BOX- -«( 4< FFFICE US'E ONLY <br />Date Receh - edr - f , 1 Application Number: 1-0 — <br />1 —+ <br />Past Reviews: YES .(7)cfeojZrulRs+dewl a NO' <br />Staff Approval "anthoi ized by: Llic i n Rorel Title: <br />Historic Preservation Commission Ret•lew Date: " 1A , � <br />Local Landmark Local Historic District (1vaw�) No i T a r� <br />E]" National Landmark w a National Register District (Name) <br />Certificate of Appropriateuesi: <br />Dented Tabled Sent To, Committee" Approved and issued: N T . <br />(Please. Print) A <br />Address. of Property for proposed Work: 1.4 '1 V.AHi11�'IE ' A •� IM <br />jSb eet IVirmber =- "Street Nam �tj� --Zfp ' Code) , <br />Name'of Property O*ner(s): ��E,IQ(,� (X/ G�L 1�Vd -Phone : ) • �7� <br />Address of Property Owner( -): 3 LA 1(AKL <br />(StreetNrtmber ='Stye t.Nam ity�Zip Cd ). <br />Name of Contrnctor(s): Phone #; <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number -� Street Name — C —Zip Code) <br />Current Use of Building: J(/?�`t'/ �4f,lfj .� I" 1 ��Lt ✓�� <br />Owner/Contractor tax #: a mAiL' <br />('Staff aril correspond frith only oire designee) / <br />X A / an <br />X"- <br />Signature or wueet _ Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />Type of Building Construction: <br />(Woad Frame— Brick= Stone - Steel— Concrete—Other) <br />Proposed Work: l ►J' 1II -I{ind ❑ Landscape .New Replacement. In kind) E Demolition <br />(more thmi one box mays be checked) <br />