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Application <br />- FOR - <br />Certificate icate of Approp iateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http:/h vww. stjosephcountyindiana. com/departments /SJCHP /index.htm <br />p: 574 - 235 -9798 f. 574 -235 -9578 e: SBSJCHPC@co.st-josepl1An.us <br />OFFICE USEOVL)5»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS nOx« ««OFFICE USE O,VLI' <br />Date Received: Application Number: <w h <br />Past Reviews: ❑ YES (DateoffastReiiek) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Rcvicw Date: <br />❑ Local Landmark ❑ Local historic District (game) <br />❑ National Landmark El National Register District (name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please print) t � _7 �i, M l L R 1& A <br />Address of Property for proposed work: <br />� <br />^ (Street Number— Street Nante —Cifj —Zip Code) <br />Name of Property Owner(s): ! 14� [AZ;A (,n A rr LLL Phone #: �j 11- 9 1 rj - Sq Z <br />Address of Property Owner(s): 107 AM6M (.A `,It/AY ISIJ I - 'C - 6- 100 <br />�J (Street Number— Street Nanie --City —Zip Code) <br />Name of Contractor(s): 640ir I L�- Phone #• �J«�• 1�' �7 52� <br />Contract Company Name: tzt* L_ Amona_l tom& ! O 1`l L' -C� <br />Address of Contract Company: W111 AMC Soo �(-� �� ?1 460 <br />/ (Street Number— Street Name —City —Zip Code) <br />Current Use of Building: ` �/� 1, <br />( Family -- Alit! ti- Faniil y— Conintercial— Goti •ernntetti— htdustrial— l'acant —etc.) <br />Type of Building Construction: 4P SAM 9- <br />Of Frcnne— Brick-- Stoite— Steel — Concrete— Othei) <br />Proposed Work: Oln-Kind ❑ Landscape ❑ New %.Replacement (not in -kind) ❑ Demolition <br />(more than one box stay be checked) <br />Description of Proposed Work: 1,2 ece, A A c,,H f <br />Owner /Contractor Fax #: �Jt"1' IhIC7 ` "l�� e -mail: yJ"'M 'C-CAIIt Y I E.ti.C. ' , (1011 <br />(Staff will correspond tirith only one designee) <br />X and /or <br />Signature of Owner Signature of Cont ?actor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />