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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 />http:// www. stjosephcountyindiana. com/departments/SJCHP /index.htm <br />p: 574- 235 -9798 f: 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE 0NL Fy » » >DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX «««OFFICE USE ONLY <br />Date Received: -1 i� �i � �� , Application Number: �V 1 — 01 J <br />s <br />Past Reviews: ❑ YES (DateofZastRewew) ❑ NO <br />Staff Approval authorized by: L h c t �Cq S 0 Title: <br />Historic Preservation Commission Review Date: <br />d Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />(Please Print) <br />Address of Property for proposed work: <br />Name of Property Owner(s): <br />Address of Property Owner(s): <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />Phone #: <br />(Street Number— Street Name —City —Zip Code) <br />(Single Family — Multi - Family / — CommercialGovernnment / Industrial— Vacant —etc.) <br />Type of Building Construction: Ai (i lr l , A(jr zi- F'ut t 6 <br />(Wood rame —Brick— Stone — Steel — Concrete— Other) <br />Proposed Work: In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) Demolition <br />(more than one box may o be checked) �^ 1 <br />Description of Proposed Work:�� /✓%'� <br />— "er /Contractor Fax M e-mail: <br />(Staff will correspond with only one designee) <br />X / and/or X <br />Signatur wn Signature of Contractor <br />fr <br />❑ Local Historic District (lvaau) <br />❑ National Register District (2vame) <br />❑ Sent To Committee MApproved and issued: <br />■ <br />(Street / Number— Street Name — City —Zip Code) <br />9 ae6 Phone #: <br />(Street Number— Street Name — Cit), Code) <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />