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ti <br />Application `�NM15SlpN fRs <br />- FOR - <br />U <br />Ceftificate ofAppropriateness o ro <br />d = <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY yt �L�co <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCIIPC@co.st-joseph.in.us <br />OFFICE USE ONLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED INTHIS BOX« OFFICE USE ONLY <br />Date Received:oo ao�ie Application Number: o� I — 0 %,o <br />i <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: - <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) <br />❑ National LandmarkF1National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: ° <br />(Please Print) ti,q� II� <br />Address of Property for proposed work: ! (3 D C • Wa"n� �t . S . S5`i (p (P i S <br />W�, ' r�- (/ _ <br />(Street <br />,Nu er—Strfeeett,Name—City—Zip Code) ' <br />Name of Property Owner(s): 1 [;L`tCi 1PW G 4' _C nk bf,,A A . 3f JGt-,yn Phone #: J3-% 4 • (v <br />Address of Property Owner(s): 1 l30 E. I,l, w �1� . S • S B 4(, C✓ S <br />P <br />�n (�,r� met CNu_mber— Street Name—City—Zip Code) <br />Name of Contractor(s): I I l� I I U) 00-k— `OVXS`yf C-� V)' Phone #: <br />Contract Company Name: t I (.R,) O -U ep C-04 -_ r (_C,), u-I"v <br />Address of Contract Company: I ( �O �. 0 C) P. Thu , fly 4(, -Sy c� <br />(Street Number—let Nam City—Zip Code) <br />Current Use of Building: J, <br />� t <br />(Siee�Family—Multi-Fa tl Commercial--Government—Industrial—Vacant—etc.) <br />Type of Building Construction: CIL/ <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />D riptio of Proposed Work: R'TIOL('_L (�,lK.t 5�N{ y� UV (> k YQ_,Vj V\)1 <br />gt� <br />Mmr, <br />a I <br />���"'� ��AA <br />\r", �VA nl A-) S , P)C (I <br />k'�C�I,Q. -sm,I 4n � S e rc elo C_u.a P .t,ti I <br />ham) 1 A)I-KA r"fi "OS 11 LNmTA EJ . <br />Owner/Contractor Fax #: e-mail: i'YtCer It iM,4, I ler'- 73�i heo . COYYI <br />(Staff will correspond with only one designee) <br />Xand/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />