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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.stjosephcountyindiana .com/departments /SJCHP /index.htm <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCHPC(@,co.st-josejahAn.us <br />. ■ 1 <br />OFFICE USE 9 NLY>>>>>>DO NOT COMPLETE ANY ENTRIES CONT IN THIS BOX «««OFFICE USE ONLY <br />Date Received: // Application Number: 2b I " - ) %-V <br />Past Reviews: ❑ YES (Date of Lon Review) [ ❑ NO <br />Staff Approval authorized by: G' 1 (' ,( CAT P C66 Title: <br />Historic Preservation Commission Review Date: n a <br />❑ Local Landmark � Local Historic District (Name) M f � 1) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) '"� / c <br />Address of Property for proposed work: ---�V Zj, A�v, ," . '- <br />(Street Number- Street Name - City -Zip Code) - <br />Name of Property Owner(s): � l�fJ 9- 1 (rte Phone #: X� -s 7154 s <br />Address of Property Owner(s): �i?y A,/ /0'e- wan-P. Jq . - A- '^'a 7 Z ) O <br />(Street Number- Street Name - City -Zip Code) <br />Name of Contractor(s): '"' + ' Phone #: -1 1-0766 0 <br />Contract Company Name: <br />Address of Contract Company: rnt�� �� ��d -�!'� •� �.���►" <br />� <br />/ (Street Number- Street Name -- City-Zip Code) <br />J Current Use of Building: / /F-- W. I /w <br />(Single Family - Multi- Family-- Cofnmercial- Government - Industrial - Vacant -etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete- Other) <br />Proposed Work: 1 KIn -Kind - ❑ Landscape ❑ New ❑ Replacement (not in -kind ❑ Demolition <br />(more than one box may be checked / � <br />� <br />Description of Proposed Work: 9- �"�' ^v a`t <br />Owner /Contractor Fax #: - � �'20o e-mail: �Xd l�'�h� OA) rle4ti6;�O, n/ C <br />(Staff will correspond with only one designee) <br />X and /or <br />Signature of Owner t ure of Contractor <br />- APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />