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Application <br />-FOR- <br />- - - -- -- -- Certificate of Appropriaten ess -- - - -- - - <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/SJCI P/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSJCBPC@co.st-joscphJn.us <br />OFFICE USE <br />/Y <br />OjN�L.YS»»>D'/ONOT COMPLETE ANY ENTRIES CONTAINED N THIS BO%«««OFFICE USE ONLY <br />Date Received: C� 02,0/itApplication Number: 4017' — A0A( 19 — B <br />Past Reviews: ❑ YES (nate *OmtReriew) ❑ NO <br />Staff Approval Athorized by: J it 04 Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />j, Local Historic District avmwe) _4" <br />❑ National Register District (Name) <br />020%'f '/O/5Ci4 <br />❑ Sent To Committee 124pproved and issued: <br />(Please Print)7�j{ V' � <br />- I <br />Address Print) <br />Property for proposed work: <br />(StreelNumber— Street Nam ity—Zip ode) I p ) <br />Name of Property Owner(s): t �-�e �T 2d Fl rayl 2 �� C t j,. Q, -J Phone #• � T p,(% ��G �� <br />Address of Property Owner(s): 191-7 i�- Vda4 i,.ei Nt4 (c X17 I Q, 1 Pt ve%, U r kt 7 6 �l uu iez 4gcy SSM' <br />l (Street Number— Street Nam <br />!e—City—Zi Code)S++�j�, <br />Name of Contractor(s): • t✓ -t ti 'f W'Okl ( J ' Phone #: J 7 V —216— 077 UPJ I <br />Contract Company Name: <br />,. YJv +ra11 IU If b 613 <br />Address of Contract Company:17 .� G) l ln/ �� <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: ,S t r" <br />(Single Family—Multi-Family—Commercia�—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: 4 r'1 e,p <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: 0 In -Kind ❑ Landscape ❑ New FA Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) e-za -r <br />p Y /� � 4 ' QZ � <br />Descriptio f Pr posed Work: 1 6k. F A P R'f'Ff aV'c„ _ d A _ {' U ,� i r, i`q t'✓t liq, T �41J�,►� <br />I Y , 3 <br />1/1%ttS 010 <br />i ) r %deb Ae. ✓4d',�.f . S'n WP 190kv Td <br />Owner/Contractor Fax #: e-mail: r%) I 13 q y{? y, I <br />r` l • C tijy� <br />(Staff will correspond with only one designee) d <br />Q and/or X <br />Signature of Owner 1-1 Signature of Contractor <br />APPLICATION REOUIREN ENTS ARE LISTED ON REVERSE SIDE— <br />