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Application <br />FOR - <br />Certificate of Appropriateness <br />6 <br />a HISTORIC PRESERVATION COMMISSION <br />Y 1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.st osepheountyindiana.com/departments/SJCHPrindex.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC tQt cost josephJn.us <br />3uYv.idaai6�:SkkS2uii•"'.. •-�•—LLwiaY.i..Yi'w:wSiYt:—rs....�.yYWLiu•y'��•'•IiYYtii4�lYiYYYYYY�YII <br />OFFICE USE ONLIy»»>DO NOT COMPS E ANY ENTRn+ 4 CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 020/, j Application Number: OW/,3 — 614V s <br />Past Reviews: YES (We0oaditmew) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of App riateness: <br />u Denied ❑ Tabled <br />Local Historic District (Name) <br />114ational Register District (Nmee) <br />❑ NO ``�nf� <br />Title: �C.�u <br />❑ Sent To Committee proved and issued: cMA7ZZD <br />(Please Print) <br />Address of Property for proposed work: <br />(Street4NWr—1 Street Name—City—Zip Code) <br />VMCName of Property Owner(s): _ Phone #: <br />Address of Property Owner(s): ,sA4NYI <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />• Current Use of Building: <br />Type of Building Construction: <br />(Street Number—Street Name—City—Zip Code) <br />oa&&- <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />t � <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) <br />(more than one box may be checkea� <br />❑ Demolition <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X /M IB- f'Y%rr <br />Signature of Owner <br />and/or <br />X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />