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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/SICHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINFII IN THIS BOX«««OFFICE USE ONLY <br />Date Received: Application Number:/� — 0519 <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: (' � Title: 1,LeZ--f_ <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark 13 -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 />(7 <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): A�i9r, / Phone #: oa ,/_ as �•3 <br />Address of Property Owner(s): � � <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): a ,r? �♦'-��i.'U� Phone #: T�VIF' ti`�r� q <br />Contract Company Name: <br />Address of Contract Company: �/ �c� Lr✓� (Street Number— Number— Street Name—City--Zip Code) <br />Current Use of Building: Ji^✓G l'� ' �J rf _')) t �J <br />(Single Family—Multi-Family—Commercial--Government—Industrial—Vacant—etc.) <br />Type of Building Construction: /Vo dic, li�y C/r <br />(Wood Frame—ffrick—Stone—Steel—Concrete—Other) <br />Proposed Work:Kind ❑ Landscape r-1New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box m yef be checked) <br />Description of Proposed Work:�'- <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 SID — <br />