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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.stjosepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f; 574-235-9578 e: SBSJCBPC@co.st-josqih1n.us <br />OFFICE USE ONLY; »> >RO NOT COMPLETE ANY ENTRES CON 17AWED IN THIS BOX«««,Ut <br />OFFICE USE ONLY <br />Date Received: _ r 0,wa Application Number: ckt; — �'�"/p <br />Past Reviews: ® YES (Dare oftar ) ❑ NO <br />II Aft, <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark neLocal Historic District (Nme) _ <br />❑ National Landmark ❑ National Register District (Naso) <br />Certificate ofAppropristeness: �y <br />❑ Denied ❑ Tabled ❑ Sent To Committee M Approved and issued: d ?G�,s?! . �.3 <br />(Please Print) i <br />Address of Property for proposed work: / <br />�1(Street Number— Street Name--City—Zip Code) �,/ p <br />Name of Property Owner(s): j i'h, I'i2C3t�Ct I'ZC Phone #s __2� �6'" S/ 127 <br />Address of Property Owner(s): <br />Name of Contractor(s): J`- A <br />Contract Company Name: T�ir-A <br />Address of Contract Company: <br />- Current Use of Building: <br />(Street Number— Street Name—City—Zip Code) <br />Phone#: .3 7y. ,;�Pvz1 3 9z 09— <br />_/a e�zrn a A, -o 440'a q_. <br />(Street Number Street Name—City—Zip Code) <br />(Single Family—Multi-Family—Commercial--Goventiment—Industrial—Yacant—eta) <br />Type of Building Construction: <br />(Wood Frame Brick—Stone—Steel--Concrete-0ther) <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: R i 40 <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X l/� I'J*i �l°C�, and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />