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Application <br />.FOR - <br />Certificate of Appropriateness <br />`e * HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosephcountyindiana.com/depmttnents/SJCBp/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJC1H?C@co.st-joseph-in.us <br />. I nn . e i I le i II I i I.b4u.u.ab:o. n�+um tid.laht. LBsNaiu.0 i <br />OFFICE USE ONLUSE ONLY <br />Date Received: t2pE. • 40/3 Application Number. owi,3 — 44 4 <br />Past Reviews: YES (DateofL.uaevtew) ❑ NO <br />Staff A Approval authorized • <br />PP b • Y• /U Title: <br />$Istoric Preservation Commission Review Date: <br />Local Landmark ❑' Local Historic District (Nang1 <br />❑ National Landmark ® National Register District (N=4 <br />Certificate of App ro riateness: <br />Denied ❑Tabled ❑ Sent To Committee pproved and Issued: A? <br />(Please Print) cc <br />Address of Property for proposed work: V Z -1G 0.. <br />(Street Numble — Street Name--City—Zip Code) <br />Name of Property Owner(s): Ph; 1 . r CL+7, Phone M �'�7 V_ ,2,U — _ / <br />Address of Property Owner(s): /0 :1—% C <br />(Sifeet berg— Street Name--City—Zip Code) <br />Name of Contractor(a Phone #: a /� <br />Contract Company N e: L e l l 914 I'q2 S L 0 K <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code') <br />rr <br />Current Use of Building:00,�erp-'k& <br />(Single Family—Multi-Family—Commercial--Government—Industrial—Vacant— etc.) <br />Type of Building Construction: ' <br />ood Frain Brick--Slone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind 11 Landscape E] New Q placement (not in-kind E] Demolition <br />(more than one box may be checked /7-- <br />D ption of Proposed Work:,(,GSL <br />10AQ -A-11 144 44WQ,A V U %f A. AAV' �. 4 Ac" 694� - <br />Owner/Contractor Fax #: , e-mail: '14j <br />(Sfa,�•}vill correspond wiWonly one donee) / <br />ro/ll�ut/i and/or X - - <br />fSignature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />