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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-josephAn.us <br />OFFICE USE ONLi'y»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««pFFICE USE ONLY <br />Date Received: <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Application Number: — <br />❑ NO <br />Title: <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) r7 <br />Address of Property for proposed work: C d 7 1,1)(,Lt(/Tu _ I <br />I - 5 &-I c -1/11 4&10 <br />(Street Numor Street Name—City—Zip Code) <br />Name of Property Owner(s): 6,\J i b 4'bre V AY+tC fes, Phone #: <br />Address of Property Owner(s): 1'7 0 4 Wakp-L-o [If �, SO0,L&1 'ls tom. � <br />0 (Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): �1('� to �, i �_ Y- J is � N-iq l _l� )�. i Phone #: J %�'" �i� l - rJrJf <br />Contract Company Name: �Ayru_ <br />Address of Contract Company: 3b y s �_Cn 1L1� �1 ��P�/11? <br />f <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: ,dt �►1�11�Pi Ate' [,C.x 4 <br />(Single Family—Multi <br />((Familll-Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: ,� (°)(�) (l '�1;� ►� l 1') <br />(Wood Frame—Brick—Stone Steel—Concrete—Other) <br />Proposed Work: 19 In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: 1i)'LL/_ i �2ClxC t l�ucc4-�- 6/� <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />Signature of Owner <br />e-mail: <br />and/or X <br />Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />