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UIT'111= <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://wvm,.stjosepticountyindiana.conVdepattments/SJCIIP/index.btm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCIIPCCqco.gt-josephJn.us <br />OFFICE USE ()JVM_>>>>DO NOT C01*1PIXTE ANY ENTRIES CONTAINED IN THIS I1OX<<<-e­0Fr1CF- USE ONLY <br />Date Rcctived:)k 11t 'DA Application Number. 0-10� <br />Past Reviews: YF_S (nate of uvt timew) M. - 61,0M � 1:1 NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />-h- <br />Local Landmark Local Historic District ,(.Vvme)T <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied Tabled F1 Sent To Committee Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: > j 1411'] <br />(Street Number— Street Nance—City—Zip Code) <br />Name of Property Owner(s), <br />Phone#: <br />Address of Property Owner(s): <br />(Stre,et'Nianber—Street Name --01h ---Zip Code) <br />A-�4Atirk;-,' <br />Name of Gontmtettvr(s): V-0 t) U, pf�4-/Vnb Phone #: 671- Me, 772,:S <br />Contract Company Name: <br />In' <br />t � <br />Address of Contract Company: t/17,1�1 4-, -9 "r 1-'> 6 b*' <br />(Street Member—Street Name—Cftj—Zip Code) <br />Current Use or Building: Z 14 t" I -r - <br />(Single <br />(lYbod Frame-Brfc"Ione--Stone-!�i creve-01her) <br />Type of Building Construction- W,0� <br />Proposed'Work: tqIn-Kind Landscape rry New ❑ Replacement (not in-kind) E] Demolition <br />LA <br />(more than one box may be checked) <br />Description of Proposed Work: _f4A044TF_ AT -10 !YA- nw.,(--P6 <br />G> rt x4ri & /IV-") 5; r <br />ipF <br />A_�__t_4 <br />Ovs-ner/Contractor Fax Me -ail: <br />(Slafj'will correspond with onir ot�le ee) m <br />---" <br />X and/or X <br />Signature of Owner Sign/t tract <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />