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Application <br />- FOR. <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stiosephcountyindWmcorn/depmtments/SJCHP/mdex.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBFC@co.st-iosq)h.in.us <br />J <br />OFFICE USE ONLY»>»DO Np r GQNZ UI ANY EN MM CQm n mn ny E Rnx«««OFFICE USSONLY <br />Date Received: Aw.t7/3 Application Number. <br />Put Reviews: ❑ YES (DsreoJLmRevkw) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of App riateness: <br />Denied E]Tabled <br />❑ NO <br />Title: <br />Local Historic District (N=4 7.4640 <br />U <br />❑ National Register District (N=4 <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 7— (0 "1 OST/q61,E <br />(Street Number—Street Name--City—Zip Code) <br />Name of Property Owner(s): -T" r I � r i t - Phone #: ;) — (6 2 <br />Address of Property Owner(s): �o ((P LLLpei.. Ave, S8 t INJ L4(p(r, (-* <br />(Street Number Street Name—Clty—Zip Code) <br />Name of Contractor(s): O W tri Phone #: a'� (a ' 6-73-5' <br />Contract Company Name: <br />Address of Contract Company: <br />/ ((Street Number Street Name—City—Zlp Code) <br />Current Use of Building: 1/ Q�CQ/Y1 i. ^ � <br />(Single Family—Multi-Family—Commercial--Government—Industrial—Vacant—etc.) <br />Type of Building Construction: - AE;C XICA�, <br />(Wood Flrame—Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape []"New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checkeaq 1 (� <br />Description of Proposed Work: �'' evWfk s'LY) S41'001 CJAr A'Lv. l 1 Ak <br />Ce OX 0 � 'hv�ldV,lti.c� -b o,.k& Ca catP, G.a ,�.�.� tr`-e�j v i ro-& <br />-Cir. <br />•� ,.,.cV� o ys___v-,�-�1'► Cider � O <br />Owner/Contractor Fax M e-mail: tom. C Go AT q m ,c.ovv,�- <br />(Staff will orrespo with my one designee) <br />1<1 <br />X �� and/or X - <br />Sitore of Own Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />