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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC'PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />1254Z Lafayette Blvd., South Bend, IN 46601 <br />http:/Jwww.stjosephdountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSXHPC@co.st-josephAn.us <br />OFFICE USE ONLY}»»>DO NOT COMPLETE ANY ENTRIFQ CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: ! 11 1 1 LA Application Number: L� I L — I U ki Q <br />Past Reviews: E]/YES ES (Date of Last Sevtaw) ❑ NO <br />Staff Approval authorized by: ) Title: <br />Historic Preservation Commission Review Date: fa rri� A <br />❑ CCA?1n Pa( <br />Local Landmark Local Historic District (Name) <br />❑ NatianalLandmark❑ National RegisterDistrict(Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />i <br />(Please Print) r-��r }} �^ _ t� <br />Address of Property for proposed work: W ``eland — , , e- rX�ll Ht 8&nd <br />r �(S�tireet Number- .Street Name—City--Zip Code) <br />Name of Property Owner(s): &_e4SO)L6Tt Phone #: 976 t�%c3in <br />Address of Property Owner(s): 5 amY _P_ <br />(Street Number—;Street Name--City—Zip Code) <br />Name of Contractor(s): Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name=City--Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: 13In-Kind ❑ Landscape IgNew ❑ Replacement (not in-kind ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: fL yl as e_ P � , build Shea b u id /, vp k' a <br />ig2S Il e it <br />• a <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X and/or X <br />Slgn�ture o*Oner v Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE -- <br />s <br />V <br />