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Application <br />-FOR- <br />Certificate ofAppropriateness r <br />HISTORIC PRESERVATION COMMISSION <br />Of SOUTH BEND & ST. JOSEPH COUNTY ti , ►� <br />125 S. Lafayette Blvd, South Bend, IN 46601 <br />hVY/ www. sOose ,com/depprtments/SJQ P /index.htm <br />p: 574 -235 -9798 f: 574 -235 -9578. e: SBSJCBPC@w.st-joseph1n.us <br />OFFICE USZ ANY Eff IM CONTARM iN THIS B0X<<<<WVFJ7W USE ONLY <br />DateRenived:0 plicatlon Number: 2A4.3 <br />t. <br />Past Reviews: YES (QsM aft" Rew-) i� I 2 4 ❑ NO <br />Staff Approval authorized by: - ,60t1 - Title: LV <br />Historic Preservation Commission Review Date: <br />❑ . Local Landmark Local Historic District pvm W %._J 1 1 <br />❑ National Landmark ❑ National RellisterDistricte*4 <br />Certificate ofAppro riatenws: <br />11 Denied ❑ Tabled ❑ Sent To Committee Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: � o , ; a <br />x- <br />et 1Vum er— el Nam"ity —Zip Code) <br />Name of Property Owner(s): � ��► (c�. t.� �,,/ I �, Phone #: .5 C�7b <br />Address of Property Owner(s): a Co r-,ek &s.e_ <br />t3treet Number — Street Name— Clip-7Jp Code) <br />Name of Contraetor(e): g ,� Phone M © <br />Contract Company Name: <br />(Weet Number — Street Name- Zip Code) <br />� 1 <br />iC %A' C` � <br />C Eamrni <br />in le ult o ta�Gbwmnen�lhdurtrlal— Yacant--etc. S g ^--C <br />(Wood Flrame— Bsic�E— Stone - Steel -- Concrete -0ther) <br />Proposed Work: ein -Kind <br />(more than one box may be checkeaq <br />Address of Contract Company: <br />• Current Use of Building: <br />Type of Building Construction: <br />3( <br />❑ Landscape ❑ New placement (not in- trine ❑ Demolition <br />Description of Proposed Work: <br />ki <br />Owner /Contractor Fax #: e-mail: <br />(Suff will correspond with only one designee) <br />X and/or X <br />Signature of Owner SI tare tractor <br />APPLICATION REQUIREMENTS ARE ON REVERSE SIDE — ``J <br />