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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />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 E 574-235-9578 e: SBSJCB?C@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COVI TLETE ANY ENTRIES CONTAINED IN THIS BOX« < 1 <br />i'2,0 -`5 <br />x n«< OFFICE USE ONLY � <br />Date Received: �`�\ Application Number: 2,0 `, — 1110-1 <br />0-1 <br />Past Reviews: BYES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />�J <br />Historic Preservation Commission Review Date: l 0-tC__� S` <br />❑ Local Landmark Local Historic District (Name) 1Z-1VtQaf <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness:CLS� 1 <br />❑ Denied ❑ TabledElSent To Committee ❑ Approved and issued: Q� ; <br />(Please Print) <br />Address of Property for proposed work: S �; r✓ 2vs�i., 41 <br />(Street Number— Street Name—Cit)'--Zip Code) <br />Name of Property Owner(s): A104�,7.Q u� SH,, Phone #: S' orfs-�Cc� <br />Address of Property Owner(s): Z6 .S- fi ,� ►'ferr`�o+- e) Q)d kltl- 1�>Al. -1-*-, INK, r 7`i <br />(Street Number— Street Name—City—Zip Code) ' <br />Name of Contractor(s): ( b l r' d2 , C Phone #: <br />Contract Company Name: U!'0../ <br />r <br />Address of Contract Company: J,.� l s > q <br />(Street Number—Street Name—City—Zip Code) <br />Current Use of Building: ,S'.., <br />(.SYfngle Family—Mulii-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: rte/®b�%/•fi�r.,� <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 />G�� 1�Cti' C j�'S�4C i4lom sror►n +k, Jl%2 <br />Description of Proposed Work: <br />f 1 .. f��,/��, i'' rr - r7 � �_ _. is � :cr .L�•iPe: <br />r <br />1"yr�;c.t, /rtl, i 1��.�`E,fR .'�( .aP�►lsc�do`l <br />1 4� /�l l/ rr 1/rtivl <br />3/ i °l �'/� S-�COv,� �l.Lt !, 1 <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X and/or X f� <br />Signature of Owner Signature of Ctor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />