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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORICPRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosephdountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC(dco.st joseph3n.us <br />M_ ... ■ <br />OFF, SE OjjNLF>>>>DO NOT COMPLETE ANY ENTRIES CONTAAMI) IN THIS BOX<<<<<<OFFICE USE ONLY <br />Date Received: i�l I Application Number: 201 L -i — I1 / l LO A— <br />Past Reviews: ❑ YES (Date of Lost Rmaw) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />0 ('--;rl 2, 0 1 ) L) <br />Eg/L( Historic District (Name) <br />❑ National Register District (Name) <br />❑ NO <br />Title: <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print)'t�, Q s <br />Address of Property for proposed work: � J�'1J �-- ►` V �/ /t <br />I (Street jNumber— Street Name—City—Zip Code) <br />Name of Property Owner(s): q 'l �/ /�Phone #: <br />Address of Property Owner(s): 1 ea44 <br />(Street Number—,Yireet Name—City—Zip Code) <br />Name ofContractor(s): /h A.tP U�7�Prf1')� 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 Fam' y—Multi-Family—Commercial—Government—Industrial—Yacant—etc.) <br />Type of Building Construction: <br />(Wood Fram Bric tone--Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape E�rNew ❑ Replacement (not in -king) ❑ Demolition <br />(more than one box may be checked) - <br />- <br />Description of Proposed Work: <br />Owner/Contract Fax #: e-mail: <br />(Staff will cone and with only one esignee <br />XOj�> and/or X <br />Signature of Owner �� Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />