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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.st osepheountyindiana.conn/depmttnents/SJCHP/index.htin <br />p: 574-235-9798 f. 574-235-9578 e: SBSjCB?C@co.st-joseph.in.us <br />OFFICE USE ONLYy»»>DO NOT COMPLETE ANY E iFc rONTA1NED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: kf a 1, . 1 Application Number.= <br />Past Reviews: ❑ YES (oauoftaaRevkw) ❑ NO <br />Staff Approval authorized -by: ffl ZOf,0 Title: ko <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District pvanKl Pi _ <br />❑ National Landmark ❑ National Register District pvax4 <br />Certificate of Appropriateness: <br />11Denied ElTabled E]Sent To Committee Approved and issued: lY • J <br />(Please Print) �U �l <br />Address of Property for proposed work:.���, o V_Tj i. 5 WV REL l R - <br />"—rki <br />(StreetNumber—Street Name—City—Zip Code)Name of Property Owner(s): V.\4 <br />Address of Property Owner(s): 1 dd W • Q RT H Effv A.8 b �L.' 50. �15U 0 , M 4 64v 17 <br />%,/1 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): v 14 V ��� �j C �.� };i' Phone #: _ A <br />Contract Company Name: V.iC1N—QM eRKa 4 U <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />• Current Use of Building: ve4LqF!4 & ,/_ y-^ &M 1 4/r <br />Type of Building Construction: K. �. �..%►y l I J ` �., <br />(Wood Frame Brick—Sione—Steel--Co trete—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: <br />Owner/Contractor Fax #: e-mail: <br />tall Wil co espond 'th only one- signee1) <br />X /�_/ and/or X <br />Sign re of O r Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />