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C <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, 1N 46601 <br />httpd/www.stjosepheountyindiana.com/departments/SJCB Prindex.htin <br />p: 574-235-9798 f: 574-235-9578 e: SWCM&O.st joseffi.in.us <br />OMCB USEONLPym» «««OFFICE USHONLY <br />Date Received: &6 Application Number. P;Wi3 <br />Past Reviews: DYES (Dere 00" RerteMJ ❑ NO <br />Staff Approval authorized by: 'Title: <br />Historic Preservation Commission Review Date: a r/ ca.,Gr/ 3 <br />❑ Local Landmark ® Local Historic District (None) <br />❑ National Landmark ❑ National Register District (Ne) <br />Certificate of Appropriateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued:. <br />■ <br />(Please Print) <br />Address of Property for proposed work: < !. L T . t� 4 rt S I" • .1 cy �t l he.�► :r �.t �� 6 /S <br />(Street Number—'Street Name—City—Zip Code) <br />Name of Property Owner(s): A, e.4 -e s A-, I:.17 Phone #: 5 7 Y l Jf 7 Z 7.? 7 <br />Address of Property Owner(s): /A 7, 3 6: <br />(Street Number—Street Name---City—Zip Code) ' <br />Name of Contractor(s): Arf- --4: T" :L' .Dc'r'L 16 • Phone #: <br />Contract Company Name: t` C, L Lr /-74f &✓=- <br />Address of Contract Company: / Z.6 D Ix., 0 4y t l o t'/n r% . � Oit vao t ,n =/ 6 637 <br />(Slreet'Number—Street Namt—City—Zip Code) <br />• Current Use of Building: <br />(Single Family—Multi Fa?)lly—Commercial—Government-4ndustrial—Vacant—etc.) <br />Type of Building Construction: .% i ►� C �; <br />(Wood France—BriclE—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: /,,'p e ,�, Tr t'r F , /r a <br />�7 L � <br />1 "r..'t?.1" f i' e '/1 >!7 Ld ✓'1 !/` 't?sP i P IWI,.Gr 7e'"1,1 •� �i7G r. C of L f s'r'• /.%!/t C <br />/ <br />;the, <br />(6 _ <br />1.4i" <br />Owner/Contractor Fax #: N) r /L e-mail: U b x r ,,1 ,ej to, n al . e <br />(Staff will correspond with only one designee) ` <br />X 11IL-1-7- C- /ice and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />