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ti <br />A <br />u A -Aication 0 <br />PP <br />FOR <br />Ce <br />rtificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST-10SE1111 COUNTY <br />125) S. Lafayette Blvd., South Bend, IN 40601 <br />littp.fl/www.stjosel)licoiitityiiidiana.com/deparinictits/SJ('I ll'/it dex.litin <br />p: 574-235-9798 f. 574-235-9578 e: SliSJCIIIIC(e()co.st-josepti.in.tis <br />OFI,*I('L-,'LISI.:O.,V],)'>. --I)() NOTCONI IT FIVE ANV ENTRIES CONTAINED INTMS ltOX<<<�<<OFFl(.Fl,St,'OtiL)' <br />' -'7r <br />Date Received: , _41�f �7 f) 1,3 Application Number: . ....... <br />.................... ........ ... ...... ... .. . ... ...... ... <br />[last Reviews: ❑ YLS g)weqfi.aAtReoew) ❑NO <br />Stiff Approval authorized by: ............. . ..................... Title: <br />...... ... ...... ..... . . .... ..... <br />Historic Preservation Commission Review Date: ............... ..... ..... ..... .... ....... . <br />FJ71 Local Landmark r7l Local I listoric District rvame) . .... ... . . ... .... ................ ......... ....... ...... . ......... ............ _ . . .......... <br />F] National Landmark ❑ National Register District jivame} <br />Certificate of Appropriateness: <br />M n <br />Denied ❑Tn L.L-1abled ❑SentTCommittee® o ommittee Approved and issued: <br />(Mixtse, Print) <br />Address of Property for proposed work:. .................... . .. 1) C., .............. <br />(Street Number. Code) <br />Name of Property Owner(s): 4,y- 0 ...................... ......... . 1. lr+Phone #:-e_(- '3,A <br />Address of Property Owner(s): <br />(Street Number SireenVame, - Cily--.7fill Cock) <br />7 <br />Name of Contractor(s): <br />... <br />....... . .zt=t" <br />C x5 <br />Rc*-f,_r - <br />ContractCompany Name: __ _ _ , ............. ... . ......................... ..... . ........ . . ........ . .. .. .... ................. I .................... . ... ........ ... ... <br />Address of Contract Company: <br />(Street A"un-ther.. - Street Nume Ciiv­ - -Z ij) Code) <br />Current Use of Building:....... ....... .... . .......... . ............. ... . . ..... .. <br />(Single erc-ial- .-Government- lndawrial­ Fcant----efO <br />Type of Building Construction: ..... .... . . . .................... <br />ff(odfi-anje -BricA....-Stanc.Steel Conerete -- Other) <br />Proposed Work:kind ❑ Landscape FIdery ❑ Replacement ((rat in-kind) 00cinolition <br />(more than one box i , b � 4,.h vked) <br />Description of Proposed Work: P V� I G- s � �11 <br />plia . . .. ..... Lk <br />1......._._. . .... .. .......... <br />..... ... .. .. <br />. ... ....... ..... <br />............ . ...... ....................................... ........... .. . . ..................... . .. ... .... ..... ......... ..... ....... .. <br />Owner/Contractor Fax It: e-mail: .. .. ..... . .. ............... ....... ....... <br />(Stuff will corre.v,pond with only (lite designve) <br />and/or <br />x <br />Sig,11,3 ire of �01V_11 r Si -nature of Contractor <br />—APITICATION REQUIIIEMFNTS ARE LISTED ON RE NTRSE SIDE— <br />