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vI <br />Application <br />-FOR- <br />Certyi"cate ofAppropriateness <br />HISTORIC'PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125.R Lafayette Blvd., South Bend, IN 46601 <br />http://www.st oseph6ountyindiana.com/departments/SJCHP/izidex.htm <br />p: 574-235-9798 P 574-235-9578 e: SBStHPC(4co.st joseph.in.us <br />OFFICE USE 0NL Y}»»>DO NOT 170MPLETE ANy ENTRIES CONTAINED IN THIS BOX«««0FF10E USE ONLY <br />Date Received: ct WOW aQl ff' Application Number: o2 Q /ic -- 160 a-_1+ <br />Past Reviews: BYES (Date efLastItedol ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />Insi Local Landmark <br />National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />(Please Print) <br />Address of Property for proposed work: <br />® Local Historic District (Name)�J <br />❑ NationalRe,gisterDistrlet(Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />131 S 1* -e Ave_ 6�;gxj, Al5(6 <br />(Street Number --Street Name--City--Zip Code) <br />0 <br />Name of Property Owner(s): . /,r/SdN {��L�AAL 12�'/� Phone #: <br />Address of Property Owner(s): <br />,p (Street Number—,Street Name—City--Zip Code) <br />Name of Contractor(s): V f 0, 0y"`1 fely Phone #: 3"711 2 a�- b <br />Contract Company Name: V le. /77Z 5 1't G <br />Address of Contract Company: <br />(Street Number—Streef Name---0ty—Z1p Code) <br />Current Use of Building: <br />(,Singl�Faml. Multi-Family—Commercial—Government—Industria! Vacant—etc.) <br />Type of Building Construction: <br />(Wood Fra a—Brie tone--Steel--Concrete—Other) <br />Proposed Work: ❑ In -Kind Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <,7,a ��eci'�' WVle <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />X <br />Signature of 0,oKell <br />e-mail: <br />and/or X <br />Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />