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s013TliApplication +`OWy1SSl0NEg8 <br />-FOR- 0J rA <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMAUSSION oo can <br />* 1865 of SOUTH BEND & ST. JOSEPH COUNTY "'y1 *►? <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />httpJ/www.stj osephcountyindiana.com/depatttnents/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCB?C@co.st-josephAn.us <br />,y IIIIYII LII i. Lllilel111YYIIliL➢ILbiILLR IIIIYLIIYIulllll Illlli III Ii niil lil Ylu1111I II fI IIi IL I I I I I <br />OFFICE USE ONL IS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: -. a4C • 020/.3 Application Number: cW 13 — O 44 !.Z f4 <br />Past Reviews: YES (Dare of L W N -kw) ❑ NO <br />Staff Approval authorized by: Title: �J <br />Historic Preservation Commission Review Date: <br />3Local landmark ❑ Local Historic District (Nome) <br />❑ National Landmark ❑ National Register District (Nano) <br />Certificate of Appropriateness: A <br />❑ Denied ❑ Tabled ❑ Sent To Committeeroved and issued: A? AM aW,13 <br />1-�,�Cpp <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Numbeh— Street Name—City—Zip Code) <br />Name of Property Owner(s): Ph; i -S�+77, Phone 2 3 2 " 8 TT q <br />Address of Property Owner(s): /0 :k —7 <br />(S eel umber— Street Name—City—Zip Code) <br />j <br />Name of Contractors Phone #: 7� <br />Contract Company N e: (. e j s1 Zq2 • S�-1 0 �l <br />Address of Contract Company: <br />(Street Numbers— Street Name—City—Zip Code) <br />Current Use of Building:0100�en(Qj - ,E�i`(ts iM tic ODks <br />(Single Family—Multi-Family--Commercial—Government Industrial—Vacant—eta) <br />Type of Building Construction: <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked) <br />ood Fram Brick--Stone—&el—Concrete—other) <br />❑ Landscape ❑ New �lscement (not in-kind ❑ Demolition <br />A4 444W.� <br />Owner/Contractor Fax M , e-mail: "JR,S 49 464 917 <br />(SIftffr <br />ill correspond wi only one ee) <br />and/or X <br />I afore of Own Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />