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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 />httpJ/www.stjosepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st jose]3h.in.us <br />OFFICE USE ONLi"y»»>DO NOT GOMPLETE ANY ENTRIES C{?NTAINED INTDIS BOX«««OFFICE USE ONLY <br />Date Received: Application Number. ;20 13 <br />Past Reviews: ❑ YES (oou ofLast Revkw) ❑ NO <br />Staff Approval authorized by: Titles <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ❑ Local Historic District (Nang) <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: <br />(Street Number- Street Name -City --Zip Code) <br />0 <br />Name of Property Owner(s): f10/ti 6,a/ Phone #: 6-1q- ,Z BT -S-, t%� <br />Address of Property Owner(s): j�,�7 J'� I MR: R s L> - - •�o vzw <br />(Street Number -Street Name -City -Zip Code) <br />Name of Contractor(s): -r 1.3 rb <br />Contract Company Name: <br />Phone M <br />Address of Contract Company: <br />(Street Number- Street Name-City=Zip Code) <br />Current Use of Building: S/ %� 1- j=.4"I <br />(Single Family-M;uullti-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 />Description of Proposed Work:. -- , <br />5!` 77--s <br />6/ )(- X71 <br />Owner/C tractor Fax #: e-mail: <br />(Stq w,I orrespond with only n designee) <br />X <br />and/or X <br />Sign ur o Owner Signature of Contractor <br />APPLI ATION REQUIREMENTS ARE LISTED ON REVERSE SIDE -- <br />GE <br />