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0J M =1 <br />-FOR- <br />Certificate ref Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND &ST. JOSE .1 COUNTY <br />125 S Laffivette Blvd. South Rend IN 16601 <br />littp://www.stiosepticoiitityiiidi,iiia.coiii/departments/SlCf IP/index.l)tffl <br />p: 574-235-9798 f. 574-235-9578 c: SBSJCfIPC(z:)co.st-jOSCPII.iB.LIS <br />ONLY VE <br />OFFICE 1 >>>>>>I)OIS'OTCONIPI.F'I'EAN'I'f:N'I'Ril OVLY <br />Date Recol oed.- *=-V " - Application Number. <br />l"wit Reviews: YES (Dj1rqf1,wAerku1 n.NO <br />' Staff Approval authorized by: liffe: <br />Historiel"reservati C)tntniision Review Date: <br />[AIC91 Landmark ❑ Local Historic District irvaslow) <br />❑ National Landmark NL <br />'ational Rtgistcr District coolaill <br />Certificatc of Appropriateness: <br />❑ Denied n Vabled ❑ Sent To Committee ❑ Approved and issued. <br />I I iollmill ill IIIIIIIIMuYUYIYIUIUIIIi uIII YU 111111111111 141.111,1111, 1 llillhYuuullllllllilllliYYllililllYlilllllllllll Iilil I4W1YY1 iIIIliI II "I'lliallilid dldlilllOi loll l ii— Im 1111 11, '11, <br />(Please Print) <br />Address of . Property for proposed <br />( Num6er.—,l Nanw—Cfty.—Zip 00e) <br />Name of Property Owner(s): -.-0 Phone #a-;) - -1 l,- <br />Address of Property Owner(s): <br />(.S4roeetlilol . ....... S treet Name.—City-7-ip CtVe) <br />Name of Contractor(s): <br />Phone M. <br />Contract Company Name: <br />Address of Contract Company: <br />(.51rcel Number —Sirew Name--Ci1j ---- Zip Code) <br />Current use or Building: <br />(single Funtr`I�Fr�I —(' rlrrtr: r< rrcial— GrtirriJtlJuJt!-...- InflJls <br />Type of Building Construction: .. I ll <br />. ... .... ...... . ...... . . .... ..... .. . ........ <br />(Wood Fhjmo-----Brick--,'Y1one- <br />Proposed Work: ❑ In-Kind f.Ulandscape ❑ New ❑ Replacement (hot in-kind) ❑ Demolition <br />(More than one bixr may he checkeel) <br />Description of Proposed Work : CUP P 1 bp <br /><r is 4r- <br />� -:ter ��� �.��:. -- �~ 1��+�..._-- �.���..1�...� r ���.�� �__���. � r,�;s , <br />Owner/Contractor Fax 4: C-mail: <br />. rill coi-it-,vl)otidivitliwivotie signee) <br />and/or X <br />Signature of Contractor <br />Siguat of Owner <br />—APPLICATION REQUIRUMENTS ARE LISTED ON REVERSE SIDE— <br />