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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.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLI'y»»>D0 NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX< -OFFICE USE ONLY <br />Date Received: ��`T Application Number: °Z/1 /Zf — �a °-1 <br />Past Reviews: ITYES (Date of LastRevien) �7�—/`7 'c�-G�� ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: 1 7 <br />❑ Local Landmark Local Historic District (Name) <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: : () r .%1\I U ; St Cdr lJ �� S c:.: i �f ? i <br />(Street Number— Street Name—city—Zip Code) ' <br />Name of Property Owner(s): 1 t i<-f-Ef14 , ^ ' r'�G`C c; tali f,�i Phone #: S'i L(- <br />Address of Property Owner(s): i cs i? l� t U� t�Sfut lr;.r %�•�iTlt �= � `1 ��.1� <br />$ (Street Number— Street Name--City—Zip Code) <br />Name of Contractor(s): Phone #: J' ty !/fr <br />Contract Company Name: il.� ., i �•i r r' 1' r �r r <br />Address of Contract Company: <br />(Street Number— Street Name--City—Zip Code) <br />Current Use of Building: �%? a1 e• �• €'4 11'? / f�1 <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: .i,�^,��-'1 A_1"olvi 13 ve t.'; <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: r 0r�t.'t,�ti <br />, <br />? �rl ��rzi I e c iG <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />3 1.� <br />Signature of Owner <br />e-mail: N kC PIA IIJ54 , r'-,1'u'ic <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />