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a <br />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 />httpJ/www.stjosephcountyindiana.com/departments/SJCIHP, mdex.htni <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josepbin.us <br />OFFICE SSR 0M S»»>DO NOT COMPLETE AW ENTRIES CONTAINED IN THIS BOR<,!s—< -OFFICE USE ONLY <br />Date Received: "'I �j I�Q Application Number. — lJ"t C)3 <br />Past Reviews: ❑ YES (Doe of LaW Ra" ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (No nd <br />Vj— <br />EINstlonal Landmark F1 -National Register District (Nonce) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee � ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 3 3 oove ) D RG t <br />(Street /Num-ber— Street Name--City-&p Code) <br />Name of Property Owner(s): Samv, S � CLh n an I1 t n a, h Phone #: (15-14) 23 4 3 b 75- <br />Address <br />SAddress of Property Owner(s): 13 V3 e A \10�j Yl e- s'% S • S6r+c, Gema .. IN 4("(0 I � <br />f_ ii (Street Number— Street Name--City—Zip Code) <br />Name of Contractor(s): Phi 1 Llajd Ri-ver <br />Contract Company Name: 4/ (21i , <br />Address of Contract Company:nZ"7`->�2� �- r �GL G� 1�e�C ...J`dQ'�%C'/1.-�✓�'ti�i / <br />(Street Number—Street Name -City --Zip Code) <br />Current Use of Building: ►r`i a 'je- i v Yl i �V <br />Type of Building Construction: �N Ood TT-avie, <br />(Wood Frame—Brick--Stone—Steet--Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ® New* -Replacement (not in-kind)❑ Demolition <br />(more than one box may be checketo C54v 1I 319 <br />#Description of Proposed Work: \NO Q Pitt 4-0 e4 Q T\A aV\j en CA05e.., 8, <br />a v)d rarer V -v a d &-h``�-� <br />Owner/Contractor Fax #: e-mail: ) ld s�� 51 F�' a}/ hoo .GDS <br />(Staff will correspond with only one designee) / <br />X Vo" and/or X <br />Sigantm of Owaer Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE-- <br />