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♦1 <br />GS <br />b <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http:/Iwww.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9378 e: SBSJCHPC@co.st-josephAn.us <br />OFFICE MEONLi>»»>P?Q T C DMPLM ANY EMIT IF CMAJNED M THIS B0X<<-<<0FFICE USE ONLY <br />Date Received: 1_0 Application Number. cng,-) 1..3 <br />Past Reviews. ❑ YES (Dee of bw Rewoq ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />Local Landmark Local historic Districtame <br />tN . <br />❑ National Landmark ❑ National Register DIstrict (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print] <br />Address of Property for proposed work: ,~) 1. C €�`a� r (P 6 0 f <br />(Street fumbers— Street Name—City—Zip Code) <br />Name of Property Owner(s): trt`t p O se m anti c �s 'hone #: 4�7cr" � <br />t <br />Address of Property Owner(s): <br />(-S&eet Numbers-- Street Name—Cit} —Zip Code) <br />Name of Contractor(,): II� ! <br />W rl eu" ` r Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Numbers --Street Name--City—Zip Code) <br />• Current Use of Building: <br />(Single Famity—Multi-Famity—Commercial--Gowrtment—Industrial—Vacant--ete.) <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: ]\� vti't C�U-t°� ii � i'^e%'I1 sal civ t� <br />�r 1 <br />r �a_ <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />XI and/or X <br />Signature of Owner Signature of Contractor <br />--APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE-- <br />