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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.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE1 USESONLi'y»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: \ . / LA . 0 2� Application Number: In1 � — C)Q,14 <br />Past Reviews: EfYES (Dare of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: S1 O Y- % <br />Local Landmark ❑ Local Historic District (Name) "�W-N S <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) l / <br />Address of Property for proposed work: �V //V j 7`0'069 <br />/ (Street Number— Street Name-City—Zip Code) <br />Name of Property Owner(s): �t�i/l0� l/� Phone It: <br />Address of Property Owner(s): i , �l <br />(Street Number— Street Name­City—Zip Code) <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Famil)—Multi-Family--Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: f lvk/0C> q,- <br />Owner/Contractor Fax Ih e-mail: <br />(Staff will correspond with only one designee) <br />1� ( ✓ l` ( /r''Ae .-I/" <br />X 9r4- t!' � and/or X <br />Signature of Owner lti��� Signature of Contractor <br />