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.1 <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, IN 46601 <br />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htin <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: iv W a6,f, 0.200 <br />Past Reviews: YES (Dare ofLaaReview) <br />Staff Approval authorized by: <br />Application Number: G A <br />❑ NO <br />Historic Preservation Commission Review Date: oW0i, J4 43 <br />❑ Local Landmark Local Historic District (Name) AU <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) �'QGI� I�((%Gt� S itlJ L�►[� <br />Address of Property for proposed work: <br />11(Street Number—Street Name—City—Zip Code) /y <br />Name of Property Owner(s): �:%rtt7V V C�(,./K�SPhone #:'f'?32 <br />Address of Property Owner(s): <br />` (Street Number— Street Name—City—Zip Code) <br />Title: <br />Name of Contractor(s): S GI - <br />Contract Company Name: <br />Address of Contract Company: <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: S 1 Aj G LF F;" ( L`'! <br />(Single Family—Multi-Family—Cbmmercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction:''�'iD <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: Kin -Kind ❑ Landscape New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: �6F w N � w� Si f. a� 7 ✓t't <br />v AILD Tb Co" &4- or, 6 AOnA & . 1AJ 1�/1 m M G(a w� �- <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />XfJO! 11 L and/or <br />Signhture of Owner <br />AJ4. <br />ri vers;dedit ve &- i;6 (- Kef" <br />X <br />Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />