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Application <br />-FOR- <br />Certificate of Appropriateness <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/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC(@,co-st-jose]3h.in.us <br />.. .l_ ■ J <br />OFFICE USE ONLYy»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«Q««OFFICE USE ONLY <br />Date Received: I t o Application Number: _U — k) V <br />Past Reviews: BYES (Date ajLan Review) 1�V \ 1 \ ❑ NO <br />Staff Approval authorized by: Title: <br />('� <br />Historic Preservation Commission Review Date: " I s ` 16 'ILA <br />dLocal Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied <br />(Please Print) <br />Address of Property for propos <br />❑ Tabled <br />❑ Sent To Committee ❑ Approved and issued: <br />41 <br />Code) <br />Name of Property Owners • P'h�one #: A;,15 <br />Address of Property Owner(s): <br />(Street N ber— Street Name—City—Zip Code) �f �J <br />Name of Contractor(s): o,14 �D/' zV,04�Phone #: Z _501 <br />Contract Company Name: <br />Address of Contract Company:r7/ <br />(Street Number—Street Name—City—Zip Code) <br />Current Use of Building: _aLle,171 <br />(S►ngle Fam' Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: / <br />(Wood Frame—Brick --- Stone—Sleel—Concrete-01her) <br />Proposed Work: - Kind E] Land scape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box m checked) <br />Description of Proposed Work: _ ��j��,1 �� l <br />" �Ab , _A <br />AAA <br />s d"/I <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X and/or X <br />Signature of Owner Signature o Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />