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Application <br />- FOR - <br />C <br />erti <br />f <br />leate <br />of Appropriateness <br />HISTORIC PRESERVATION COXIMISSION <br />of SOU1711 BEND &. ST. JOSEPH COUNTY <br />125 S I dayettc Blvd.,1Zn,,d, Bend, TM AAKn I <br />http://www.stioser)bcottntyindiana,coni/department:`��/SJCI.lPj'itidex.litrn <br />p: .574-235-9798 f. 574-235-9578 e: ..SBSJCH1'C@co.st-joscphJn.us <br />... ...... . . . . ............ <br />OFMI'Mr. ONZ I",>>>>> DO N(,rl'(,'()NiPLlq'P ANY ENTR I ESC ON TAIN ED IN TIM;BOXe<<<<<0FF10E USF, ONLY <br />Date Received: L.,Jc/ 3 Application Number - <br />1,2 <br />Past Reviews: n YES (Pate ,,rLUtRe;iq FINO <br />Staff Approval 3uthotized by: <br />Title: <br />historic Preservation Commission Review Date: <br />❑ Local Landmark ,OcAl historic <br />❑ National Landmark National Register Districtex—tV <br />Ctrtificatc of Appropriateness: <br />nDenied FJ Tabl"I El sent ToCommittee FJ Approved and Issued, <br />(Pltwe Print) 7) <br />Address of Property for proposed work: <br />.. . . ...... . ........ <br />(Street'Manber Street.,Vurne—Q3­ Zip, Code) <br />Name of Property Owner(s). td' UM%S_......_._......___ Phone #: <br />Address of Property Owner(s): <br />(Strdet,Vtur ber— Street Nah7e—Cjty--Zip Code) <br />Name of Contractor(s): Phone H: <br />Contract Company Name: _ <br />Address of Contract Company: . .. . . .... . ........... I <br />(SO -eel Nuinivr— streetivam?,-- ?J�Y—Zip Code) <br />Current Use of Building: 1,L kL . . ......... . . ... ..... ... ... ... . <br />(Single --- etc) <br />Type of Building Consfruction: 4" "P � <br />(1146od <br />Proposed Work: ❑ In -Kind F Landscape Ej New Replacement (not in-kiml) El Demolition <br />(m, ore than one box maj, be checked) <br />Mscription of Proposed Work: 'Isevz-, 14,101, ... .. I .W,/,ry <br />.. ... .... ......... .. . ........... . <br />Owner/Contractor Fax #: <br />(StaM'I co , nd with on,5, one designee) <br />Signa -t re of 03w er <br />le <br />e-mail: <br />anti/or X <br />signature or Contractor <br />—APPLICNFIONKREQUIREMENTS ARE LISTED ON RENTMSE SIDE— <br />