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Application <br />..•..,.,.;,t,, �, -FOR- <br />,�� Certificate of Appropriateness <br />�► HISTORIC PRESERVATION COMMISSION <br />1865 + of SOUTH BEND & ST. JOSEPH COUNTY <br />17551S Lafayette Blvd., South Bend, IN 46601 <br />httpJ/www.st osephcountyindiana.comtdcpartments/SJCHPJmdcx.htm <br />p: 574-235-9798 f•. 574-235-9578 e: SBSJCHPCQu cost joseph.in.us <br />Y ii null hl I n <br />OFFICE USE ONLiti»»>gQ 9j COMPLETE ANY E,�'= 3 CONTAINED IN THIS BOA«««0FF7CB USE ONLY <br />Date Received: .1 013 Application Number. aP01,Y — 4f#22.4 <br />Past Reviews: ❑ YES (BarsofLa98evkw) ❑ NO <br />Staff Approval authorized by: 1_ Title: <br />t <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark blLocal Historic District (N.0 <br />❑ National Landmark ❑ National Register District (Nmae) <br />CertiScateofAppro riateness: <br />Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) (a 7G ,y � <br />Address of Property for proposed work: I �� <br />(Street Number -Street Name -01 <br />,P -Zip Code) <br />Name of Property Owuer(s): jq 1 �-AGd-" J • .�i: v 1 n ���1 Com- Phone #: ;1-76 - (6-7 25 <br />Address of Property Owner(s): �(i t �P LQ'S'e� - t�ttt�- t i L4 tq( n tq- <br />(Street Number -Street Name -City -Zip Code) <br />Name of Contractor(s): Q W 4yQJ�--• <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: V ozami. r <br />(Single Family127 <br />- <br />Phone #: - ' 677 �t-5' <br />(Street Number- Street 1Name-City-Zip Code) <br />W. <br />Type of Building Construction: \C.V <br />(Wood Frame Brick--StoneSteel-Concrete-Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ' New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one bar may be checkeaq <br />Description of Proposed Work: J��vt� <br />ce 0'r a �vWAA,rv.t� -tv c' -&d,._ <br />Me rn a,t � {rt,o.f. Q , %�i �T � . 4-.1 wzs �m�� � •-�errv�a_.. -b � <br />Owner/Contractor Fax #: a-maii: YYtOA a a Q --i . Se'a t .%2 <br />(Staff willorre pod with n/y one designee) <br />X and/or X <br />Sl tore of Own Signature of Contractor <br />>_ APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE-- <br />