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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 />http://www.stjosephcountyindiana.com/departments/SJCBP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSjCBPC@co.st-joseph.in.us <br />OFFICE USE ONLYy»»>DO NOT COMPLETE ANY ENTRn;S CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: -,,2 df). 0&a Application Number. <br />Past Reviews: ® YES (Dare of Lan ) ❑ NO <br />Staff Approval authorized by: I " Title: Auz&u 2 _ <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark neLocal Historic District pvame) <br />0 <br />❑ National Landmark ❑ National Register District pvame) <br />Certificate of Appropriateness: _ I <br />❑ Denied El ❑ Sent To Committee Approved and issued:19 <br />.11 a <br />(Please Print) <br />ei <br />Address of Property for proposed work: 6 / <br />Name of Property Owner(s): T P/ <br />Address of Property Owner(s): <br />Name of Contractor(s): Jay L) —C:': <br />or 7 <br />(Street Number— Street Name—Cit)A—Zip Code) p -7A_&A tCWCAC Phone #s�� `'` /� <br />(Street Number— Street Name—City—Zip Code) <br />Phone #: 5,74" &�Z/ 3 NO -7 - <br />Contract Company Name: 7-n t () a/la <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />• Current Use of Building: <br />(Single Family—Multi-Family--Commercial—Government—Industrial—Vacant--etc.) <br />Type of Building Construction: <br />(Wood Frame Brick—SioneSteel—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: iGO47 <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />