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V <br />Air 1, is ation <br />- FOR - <br />Certificate nf'Appropriateness <br />HISTORIC PR PS !7 ". VATION COMMISSION <br />of SOUTH BEN: %,', ST. JOSEPH COUNTY <br />125 S. Lafayette 1? 1-1 South Bend, IN 46601 <br />http://www.stjosephcountyi ncl i:i iia.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9571 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE' I I7E'OtNLT»»»DO NOT COMPL! "+'!:.+.'_• _!�' �-S CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 512.1114_ ApplicnCon Number: UN —01502 - <br />Past <br />01502Past Reviews: 10 YES (Date ojLasl Review) U 61 ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Comm ksion Review Date: MrW I t i l-Oq <br />1 1 1ni�� <br />❑ Loc;;I l,,unlmark � I.nc:; ";storicDistrict (Name) L-��li �• <br />C� Naliunal Landmarkn," " rister District (Name) <br />Certificate of Appro,,r-+rteness• <br />Ell Penied. ❑ Tilled ❑ Ser' ''' r C linmittee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: l q( 2 "/Ya <br />(-%':n •I Number— Street Name--City—Zip Code) <br />Name of Property ('item -1: Yd K - (-,n- f Phone #: 5 -7 <br />Address ofPropert.• Owner(s): Sow Zel-6 2 �L ���� .✓t-� cEI�S''�i�o <br />( ' : tuber— Street Name—City—Zip Code) <br />Name of Contractor(,): t�� Phone#• 9C(1 -(3v 7 <br />Contract Company Name: <br />Address of Contract Corn pwI•.v: <br />:`,',rmber— Street Name—City—Zip Code) <br />Current Use of Bit" "ny: <br />(Single Family—,1: r,': '"'ommercial—Government—Industrial—Vacant—etc.) <br />Type of Building Co- -r!,• :on: <br />Proposed Work: L_: !r -find <br />(more than one box mnv he r' • rl) <br />Description ofPropo,,,­ ' <br />larick—Stone—Steel—Concrete—Other) <br />❑ Landsc:) New EfReplacement (not in-kind) ❑ Demolition <br />—,� E <br />Owner/Contractor F,rx #: <br />(Staff will cor s onrr gv (),?e�.r,e designee) <br />X <br />Signatur w r <br />X <br />Signature of Contractor <br />