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a <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/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />. i_..1 II <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 'JG1,3 Application Number: o2G%l�3 / �5- <br />Past Reviews: ❑ YES (Date of Lasa Review) 1 h1 NO <br />Staff Approval authorized by: i i` Tide: <br />i <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) j <br />X Address of Property for proposed work: 13i1 6 • �,q✓/Ve Ad �L w <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): &6tjN iF- Tu 1f _ Phone #: <br />Address of Property Owner(s): cJ /i7 o j <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): �rar j1p j G.. Phone #:7;rV-cl' -- <br />Contract Company Name:rIG 4.r Address of Contract Company:^"" S� O/J K��(Street Number—Street Name—City— de) <br />Current Use of Building: �d n 1� "x- rc .'i �� <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />�} t <br />Type of Building Construction: i"( (Z D y4�� <br />(Voozi rame BrickBtone—Steel--Concrete—Other) <br />Proposed Work:In-Kind <br />(more than one box maj %bechecked) <br />❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />Description of Proposed Work: T'��0 ` ` + &f/f, C -R- <br />6 0"A l r 1 �� �^G•l 69'1 <br />j <br />I <br />bdlo�f <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) , + <br />X and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />