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\,. o <br />SpUTH B� Application oµN�5510ryE <br />04 Pt4i�!;t(u 'gyp it�� �6� R'ro <br />F \� -'TOR- SJ <br />Certificate ofAppropriateness o T <br />HISTORIC PRESERVATION COMMISSION o co <br />7865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.st osepheountyindiana.comtdepaTtments/SJCBPrmdexhtn <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st joseph.in.us <br />OFFICE USE 0AMr»»»710 NM' C0NE <br />MPLFM ANY FNMrES CONTAID IN TRIS nf1R«««OFRCF USE ONLY <br />Date Received: <br />11.15. I Application Number: 7&q III ✓ A <br />Past Reviews: ❑ YES MeefLWR--0 <br />Staff Approval authorized by: <br />❑ NO <br />T'rt1C <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark dLocal IGstorte District ff—d <br />❑ National Landmark ❑ National RegisterDistrict(N-4 <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) 1 .• <br />Address of Properly for proposed work: ((V-� �t 1 —Al <br />trees Nwnber�IreelNanse—City--I$Code)Name ofProperty owner(s): Y� �(�C,C p��i e `� Phone #: <br />Address of Property Oivner(s): Cl <br />►y� <br />(StreetNumber—rStreetName--City—Zip Code) r� <br />Name ofContractor(s): lAarn-r S-PkAil-PA Phone#: 114>H 11� <br />Contract Company Name: <br />Address of Contract Company: (DLlJ I i L�� I �f / i I P <br />(Street Number— Street Nmne-0i Z,ip-Cpode) <br />�rrent Use of Building: 1 nQ �q .6t tin 1 " t �.P �/ C' `-tt fl 1 -1 <br />(Single ily—t�lu amf m retal--(,overmnent—Industrial—Vacant---eta) <br />Type of Building Construction: AfJC4 - <br />(Wood Fmme—Brick—Stone—Steel—Concrete-0ther) <br />Proposed Work: ❑ In-IGnd ❑ Landscape ❑ NewReplacement (not to -kind) El Demolition <br />(more than one box may be checked) / <br />11 <br />Description of Proposed Work Q (� <br />G!��D 1--P h fr G — dY )i r1n r�� F.P ,r�r�tAN k 1 <br />r - <br />Owner/Contractor Fax #: e-mail: c R <br />(Sta(j ill correspond wit 11 one designee) <br />\ <br />and/or X <br />Si to of r offracto <br />APPLICATION REQUMEMENTS ARE t <br />ON REVERSE WE <br />*SQ(\6 <br />E <br />*SQ(\6 % <br />C", 7n-\--- act <br />