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Application <br />-FOR - <br />Certificate of Appropriateness <br />p <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd Bend, IN 46601 <br />http: / /www.stj osephcountyindiana. com/departments /SJCHP /index.htm <br />574- 235 -9798 f: 574- 235 -9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLY» » »DONOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX.-OFFICE USE ONLY <br />Date Received: I - Iu,4ti.F?' .20/ 0/ Application Number: --PLO 11 — 0 *lq <br />Past Reviews: [�<S (Date of Last Review) S �D �` ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Local Historic District (Name) , 9 <br />E National Register District (Name) ' <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) p rty proposed osed work: Address of Pro a for ro ] (� � r►� (� • 69 <br />_ (S \ treet Number — Sfeet Name — City —Zip Code) `�+�— <br />Name of Property Owner(s): 1_�-t �,� j 1 A 1 Y� < < ./ Phone #: ,�©" O� 3 <br />Address of Property Owner(s): <br />N treet Number— Street Name — City -Zip Code) <br />Name of Contractor(s): Phone #: <br />v <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name — City —Zip Code) <br />Current Use of Building: r n R m i <br />(SinglElamil — Multi - Family— ommercial— Government — Industrial — Vacant —etc.) <br />Type of Building Construction: ( (D <br />'(Wood Frame - Bar' k—Ston te—S eel— Concrete— 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: jj a - <br />r <br />Owner / Contrac ax <br />(Staff will corn spo ith ly one designee) <br />X• <br />Sign r Owner <br />°- , jQX C <br />e -mail: <br />and /or X <br />Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />