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Application <br />•FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND d: ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd, South Bend, 1N Agni <br />httpJ/www.stjosephoomWadiana.col/depmftents/Sjcw mdec.htm <br />p: 574-235.9798. E 574-235-9578 e: SBSJCHPC@co.st jos;*in.us <br />0MCEUSE <br />ppo��N��Z��USE onY <br />Date Received: Jr.(iG1r,f -AV /3 Application Number: <br />Past Reviews: ❑ YES (DWvfrr rite uw) ❑ NO <br />StatfApproval authorized by: t Title: <br />Historic Preservation Commission Review Date: <br />Local Landmark ❑ Local Historic District (Now <br />❑ National Landmark ❑ National Register District pvmo <br />Certificate ofAppro riatenem: <br />Denied ❑ Tabled ❑ Sent To Committee Appmed and Issued: <br />s <br />(Please Print) r . , r I / <br />Address of Property for proposed work: ' 1 'i S � is -r t' nwi Ai i P, SOLA /9 CA d f :)w 4(0& l �p <br />/1 1 (St vet Number— Street ftmOLCity�—Zip Code) <br />Name of Property Owner(a): C,- j11 l'( `I d n t I -f e Phone #i: <br />Address of PropertyOwner(s): (Dl Y SApj,,:Yn art <br />Li <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): L("n40P, n d s p Phone #: <br />-- - <br />Contract Company Name. G -Y �C I ti'lol <br />Address of Contract Company: <br />(Street Number—Street Name—City—Zip Code) <br />• Current Use of Building:—S';r? C e �?ivty yv <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—SteerConcrete—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: SCC h )a <br />Owner/Contractor Fax M o•mail: <br />(Staff wi correspond with only one des <br />X l,, L and/or X <br />Signature of Owner L. Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDl?,-- <br />