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Application <br />-FOR- <br />Certi ICate 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. 574-235-9578e: SBSJCHPC a(),co.st-josephJn.us <br />■ <br />OFFICE USE ONL�Y>>>>>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««ptFF10E USE ONLY <br />Date Received: -� �� t-� Application Number: 2 '— 0)� `4 <br />Past Reviews: ❑ YES (nate of Lon Review) i=1 "O <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certilicate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Title: <br />Local Historic District (Name) ch61. l yl Pair r_ <br />I <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) /2 /") )J/ �jii yy`�l S'/>�/f l 1h% !•l ,j�j /(j <br />Address of Property for proposed work: t/ _/ �7' 1 t►s /� V <br />(Street Number— Street Name—City--Zip Code) �' <br />Name of Property Owner(s): <br />+► %A Phone #�9^ go?_�..i 3 / V <br />22 <-14 1�� + S't � e /A/ 4- G 6 ) <br />Address of Property Owner(s): <br />(Street NumTer— Street Name—City—Zip Code) <br />Name of Contractor(s): , Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />e� �+ (Street Number— <br />, Street Name—City—Zip Code) <br />Current Use of Building: J.114 b L t V/4 !� L 1r <br />(Single FambrIvIn <br />ily—Multi-Famil/y—Com,(mercia"overnment Industrial—Vacant—etc.) <br />Type of Building Construction: r 1 [?A�ij—=:;. <br />(Wood Frame—Brick—Stone—Steel—Concrete--Other) <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked) <br />Description of Proposed Work: <br />❑ Landscape ❑ New ❑ Replacement (not in-kind) Demolition <br />005M0/_/sA_� <br />Yom h3tps <br />L4OrO, k---- d arAtzcif- <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designe ) <br />X and/or <br />Signature oj 94ner <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />O TAUT g 14 /gib <br />X <br />Signature of Contractor <br />