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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: SBSJCHPC@co-st-josephAn.us <br />OFFICE USEONLIy»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN TH BOX<<<OFFICE USE ONLY <br />Date Received: 1,2 °u'y Application Number: a01 el�-- <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 />NO �%f ,r� <br />PAW Title: itJ'ti'E-e z% ;b_ <br />Local Historic District (Name) /Cle • L5 <br />❑ National Register District (Name) <br />❑ Sent To Committee rl Approved and issued: 1,2 ?Tlet` I <br />(Please Print) <br />Address of Property for proposed work: `/ tt' s4• 4ovVbj&m1 <br />(Street Number— Sir et Name—City—Zip Code) <br />Name of Property Owner(s): Am to �� Phone #: <br />Address of Property Owner(s): W ll AA Aid/Al "v / 4�3 7 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s):�/2eat1�''e _k1hoc-!`.fif Phone <br />Contract Company Name: . i 4 <br />Address of Contract Company: . 2gl As/La*ja <br />Current Use of Building: <br />Type of Building Construction: <br />(Street Number— Street Name—City—Zip Code) <br />F,.;/w -114C,0 <br />(Singre Family—,Multi-Ftfmily—Commercial--Government—Industrial—Vacant—etc.) <br />(Wood Frame—Brick—Stone--Steel—Concrete—Other) <br />Proposed Work:In-Kind ❑ Landscape ❑ New ❑ Replacement (not in-kincO ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: /,A144e01v1 <br />r <br />34a� ra atod fe LeAoceZa� <br />Owner/Contractor Fax #: , e-mail: <br />(Staff will correspond with only one designee) <br />X <br />Signature of Owner <br />and/or <br />44 c• d aw S <br />X .� <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />ev S <br />