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Application <br />- FOR - <br />Certi Kate 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 osepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE�'USSE�ONLYY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: -sem- -� Application on�ation Number. <br />Past Reviews: YES (Date ajlast Review) ��E ��—T ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: � tw I q <br />Title: <br />❑ Local Landmark Local Historic District (Name) IG.wQr r1f .✓ dz <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />■ <br />(Please Print) <br />Address of Property for proposed work: Q; c,, 4& 6 <br />J <br />(Street Number- Street Name -City -Zip Code) <br />Name of Property Owner(s): �, f� r�,� Phone #: <br />Address of Property Owner(s): /-4.6 1hN--' <br />(Street Number- Street Name -City -Zip Code) <br />Name of Contractor(s): ,A Phone #: a -I „ —g67S4 <br />Contract Company Name: <br />Address of Contract Company: <br />CC (Street Number- Street Name -City -Zip Code) <br />Current Use of Building: V 1 1� rgly ), t 1 <br />(Single Famyyil-Multi-Family-Commercial--Government-Industrial-Vacant-etc.) <br />/ <br />Type of Building Construction: Wood- iso G, f r-'ra rre/ <br />(Wood Frame -Brick -Stone -Steel -Concrete -Other) <br />Proposed Work: do -Kind ❑ Landscape ❑, New dReplacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description. of Proposed Work: 10 P C i f Aj / i WIZVZ�L41� 0"11I <br />1 1. 11 sv <br />U!1(� <br />&416'r7 i 69)c� �f L / <br />Owner/Contractor Fax #: R 7 "�O LU email: (J& T� r t to V V a hd o t CP YLI\ <br />(Staff will correspond with only one designee) <br />t <br />X/;10Oand/or X <br />Signatu of Owner Signature of Contractor <br />-APPLICATION REOUIREMENTS ARE LISTED ON REVERSE SIDE- <br />