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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/SJCBP/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE ONLY >> >eDO NOT COMPLETE ANY ENTRIES CONTAINED IIN`THI««« <br />S BOX^OGFFICE USE ONLY <br />\ <br />Date Received: Ov 2�t '1 Application Number: /,Olt <br />Past Reviews: ❑ YES (Date ojLast Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: / <br />❑ NO <br />Title: <br />❑ Local LandmarkLocal Historic District (Name) _AA1 Ilk rl JA <br />❑ National Landmark)❑ National Register District (Name <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: J` ®r b v,5.t 3- At/r=__ Sou -1 1-F- O r A-rP <br />(Street Number— Street Name—City—Zip Code) a� <br />Name of Property Owner(s): ��� �� A- L_ 15 tw_ 6z_ S Phone #: <br />Address of Property Owner(s): j o t i 1 V r K-- 4Va—_ <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />Type of Building Construction: <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked <br />Description of Proposed Work: <br />Phone #: <br />,�ca d's e,:�- <br />(Street Number— Street Name—City—Zip Code) <br />;(AVaFraml':—' ick—Stone—Steel—Concrete—Other) <br />❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />Owner/Contract r F#: <br />(Staff will corres on with one de ghee) <br />X 4 A.. <br />Signature o ()wner .T <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />e-mail: <br />and/or X <br />Signature of Contractor <br />