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Application <br />-FOR- <br />Certificate <br />FOR- <br />Certi icate ofAppropriateness <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/SJCB P/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE OO/NL Y»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: / 4% �J-% Application Number: a,61 <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: % T /� � _401 _ <br />❑ Local Landmark Local Historic District (Name) !y/ .�/;c�Z, <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) (P I1"�s p <br />Address of Property for proposed work: •J l" ST <br />(Street Number— Street Name—City—Zip Code) 1 1 <br />Name of Property Owner(s): it l V h t✓ - C o 0 /,XPhone #:�7 7 � 1T '��� <br />nt <br />Address of Property Owner(s): � � � I � �a.YT � S �� f <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): S u -e ' Fe-rl C Phone #:.6-77 <br />Contract Company Name: ��- e !�L5 <br />Address of Contract Company: J,1-3 "% -7 <br />Current Use of Building: <br />Cc. b 0 V 'ice <br />(Street Number— Street Name—City—Zip Code) <br />(Single Family— <br />)Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />00 me Brne—Steel—Concrete—Other) <br />Proposed Work: ❑ l:n-Kind ❑ Landscape New ❑ Replacement (not in-kind ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: 61 <br />_ i r! Va-C Pen C& l )'1 C/ OS <br />ha,CAL xeL r4 / <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />e <br />and/or X <br />Signaturk,of Owngr Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />