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Application GgWM�SSIgNpRS <br />FOR <br />OJT fA <br />C m <br />Certificate of Appropriateness <br />p b <br />HISTORIC PRESERVATION COMMISSION `m �' o <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46661 <br />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />MMOMMW <br />OFF/CE USE ONUS> >>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: tom% AT a0/7• Application Number: C�O17' — L) 8.2— 7 <br />Past Reviews: ❑ YES (,DareofustReview) ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: ISyf., ,X, .2.40 1 `7_ <br />❑ Local Landmark © Local Historic District (Name) `��d�✓ <br />U <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />'T�t' <br />�' (Street Number— Street Name—City—Zip Code) rr <br />Name of Property Owner(s): 3Cwo daviSr Phone #: a0. bt�,7,17 <br />Address of Property Owner(s): �� SI�iAq— <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): 1F...., Phone #• <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: q A(L, ( <br />f(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: ❑ In -Kind ❑ Landscape 1KNewReplacement (not in-kind) ❑ Demolition <br />(more than one box may be checked)p + � <br />Description of Proposed Work: l)'g <br />(%. [:��p�=—Ick" <br />Owner/Contractor Fax #: e-mail: c • di Nh; 1, eta <br />(Staff will co spo with only7�� <br />X and/or X <br />Signat of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />