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0 <br />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. stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE <br />%USE OO(NLY%»�»»DO NOT COMPLETE ANY ENTRIES CONTAINED INTHISBOX«««OFFICE USE ONLY <br />Date Received: ` (i 1 1 t / Application Number:t7111 <br />Past Reviews: ❑ YES (Date oJLastReview) ❑ NO <br />Staff Approval authorized by: C__� D �'e. qS 4 Title: <br />Historic Preservation Commission Review Date: �� a <br />❑ Local Landmark ❑ Local Historic District (vame) i h Par K <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee Approved and issued: <br />(Please Print) L v Z Sd 1,- 9CAL' <br />Address of Property for proposed work: Sa`s Al aT'� G�-:t pkv �t''�- IV <br />(Street Number— Street Name—bty—Zip Code) <br />Name of Property Owner(s): &4CON ► lk s SKl�lJ Phone #: 57Y-447-712;4 <br />Address of Property Owner(s): 6 �S N / 1 � SA N J�r�� SO.+:�� �i�rG , _T 4j /aid <br />(Street Number— Street Name--City—Zip Code) <br />Name of Contractor(s):_&rK " i a_S Phone #: <br />Contract Company Name: Q.y 1 <br />Address of Contract Company: 1AT7 /t'1iske'tV4ks �V{' I SOA Tj� tTiv <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: SF—;L <br />(Single Family—Multi-Family--Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: S 15n1 <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape nj New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: MW $n++11 NOr+—T�4iN• (�d�� s- p�i�t� S;,�N <br />Ch &'a > %O SC—.a Zone i N C Szs <br />Owner/Contractor Fax #: � %7 a-mail:(+iNa <br />(Staff will correspond with only one designee) <br />X Ph v -"e' Z (Zt 1P %and/or X <br />Signature of Owner Signature of tractor <br />