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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.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJC1HPC@co.st-josephJn.us <br />OFFICE USE ONLi'y»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 22Ok�ZO-k3 Application Number: oW /3 — D 4.22 Al' B <br />Past Reviews: YES (Dace oftan Review) � j d ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />2013 <br />Iff"Local Historic District (Name) <br />© National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) / ) l P /� <br />Address of Property for proposed work: /J la D i' A e fl VE'. 5l� v ��P /�ti� <br />j (Street Number— St et Name—Cit LZip Code) �1 >/ <br />Name of Property Owner(s): / (cc l't 4,4 W �� 11 A w► t///a r1/Z)!�c Phone #: �7 �/ tv 4'% g <br />Address of Property Owner(s): 01 L &D& rVP.. S� vl � 4. �' + –7/1/) 41a07 <br />(SIreet Number— Strdet Name—City—Zip Code) <br />Name of Contractor(s): v L✓ 0 e r <br />Contract Company Name: <br />Address of Contract Company: <br />Phone M <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Family j—Multi-Family—Commercial—Government Industrial—Vacant—etc.) <br />Type of Building Construction: <br />'(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape L151 New P1 Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) �T <br />Description of Proposed Work: U c' �Pf/1 W / ie n <br />Owner/Contractor Fax #: e-mail: /y1 i G[ -i Ate' .' 7� til h t✓i . �,.� <br />(Staff will co espond nl o/nee%d�ignee) <br />X �.. �,� .i ./,.��I-el and/or X <br />Signature wner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />