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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/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPCna,co.st-j�osej)h.in.us <br />1L. Jai M L I <br />OFFICE USE <br />�O�N"L� Y>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: ' ^"7 a��� Application Number: Cke'v"If <br />Past Reviews: YES (Date of Last Review) NO <br />LGr✓ 02 0�3 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) (,+rte–rte lk <br />❑ National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑Approved and issued: 5'o2Dy� <br />(Please Print) / d > <br />Address of Property for proposed work: t r � rcJ <br />(Street Number— Street Name—City—Zip Code) <br />f � <br />Name of Property Owner(s): 7tk,., S 4– t<ri %-I � *�► J!5' Phone #: <br />Address of Property Owner(s): <br />(Street Number— Street Name—Ci(y—Zip Code) <br />Name ofContractor(s): Phone#: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: D -S' <br />gle Family—Multi -�amily—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick--Stone—Steel—Concrele—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New • 'r Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />P P > , .r.,?r�, ,► J1– c A U1,14 � i.✓t �c,i'C1 c14 C) <br />Description of Proposed Wor/k�• t'1 <br />lni•W'A�l.J�-i trxlt <br />e'1 i �c TfZ. _ u9+/1 L.� rn ��_ I �+� A— , <br />�f'e(c•t.�c li41 V��l �i fS1 �%�'��✓ Li1 .`>�:�✓�, <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />