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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 osepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephAn.us <br />OFFICE USEq ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED <br />SIN THIS BOX«««OFFICE USEONLY <br />Date Received: `) �� C1 ,� Application Number: L -M 1 — l.� I Cl <br />Past Reviews: YES (Date of Last Review) w ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />M' 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 />A <br />(Please Print) <br />Address of Property for proposed work: __7 d o <br />(Street Number— Street Vie—City—Zip Code) <br />2 !_ 1 <br />Name of Property Owner(s): 0 6t � TXV,..V_ Phone #: ,g /4 q' � q,& � �) j <br />Address of Property Owner(s):(/ a, , w {r �+ �` r 1.0 <br />(Street Number— Street Name—City--Zip Code) <br />Name of Contractor(s): S `d-- Phone <br />Contract Company Name: <br />Address of Contract Company: &,� <br />�M 'V^4 <br />' (greet Number— Streeikame—Ci(y—Zip Code) <br />Current Use of Building: <br />(Single Family—Mttlti-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 />l <br />Description of Proposed Work: _ �VL 8 r N ' S Vt- <br />e <br />Owner/Contractor Fax #: Jz �' .�S e-mail: a iY't a fO' SOtlt ��h�I�j�i% <br />(Staff will corresp nd wit only one designee) <br />and/or X <br />Sig a of Own Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />