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S ouT.R Application <br />- FOR - <br />\\ PFACB / �' Certificate of Appropriateness <br />'tx m HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST, JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http: / /www. stj osephcountyindiana .com/departments /SJCHP /index.htm <br />p: 574- 235 -9798 f: 574- 235 -9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX «« «OFFICE USE ONLY <br />Date Received: 131 7/z ``�' `�� � Application Number: a / S — OS 3 / <br />Past Reviews: DYES (Date of Last Review) <br />Staff Approval authorized by: <br />FEM <br />Title: <br />Historic Preservation Commission Review Date: AC/ f. / S <br />❑ Local Landmark Local Historic District (Name) �G't <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: �� S -,..- <br />(Street Number— Street Name — City —Zip Code) <br />Name of Property Owner(s): Phone #: <br />Address of Property Owner(s): S 3 t 5��� ��.,� 3r- S �. �E 5_b- t—ct t L CG <br />(Street Number— Street Name —City —Zip Code) <br />Name of Contractor(s): S e--( `l — L , z _ �; - Phone #: <br />Contract Company Name: <br />Address of Contract Company: ' <br />(Street Number— Street Name — City —Zip Code) <br />Current Use of Building: L A-� — S r- <br />(Single Family— Multi - Family — Commercial — Government Industrial— Vacant —etc) <br />Type of Building Construction: _�111. ✓ I <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ® New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) <br />� ^ P•GkC <br />� 7— <br />Description of Proposed Work: :o '- DY C w r Oc -�a <br />rte) r - rN 7`wVO C- 9:65 Pt =- e. /7G r 4,,w 6018 At 17 - 7,�= 6 <br />Owner /Contractor Fax #: - e -mail: L.L_ —j U'A <br />(Staff will correspond with only one designee) <br />X and /or X <br />Signature of O� r Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />