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N <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />m� HISTORIC PRESERVATION COMMISSION <br />865 x 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-josephJn.us <br />" 11 '•" 11 f'.'I1 i1'IY 'OFFICE USE ONLYS»»>DO NOT COMPLETE+ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: e�Og� yP AO (S Application Number: <br />Past Reviews: 19 I S (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />❑ NO <br />Title: <br />Local Historic District (Name) <br />ED --N' Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />1 <br />(Please Print) <br />Address of Property for proposed work: d � �9 Ll <br />(Street NuPmbe>t Street Name—_City—Zip Code) <br />Name of Property Owner(s): \ ` �1Ghone #:jF'�s(J–®'��j j <br />, <br />Address of Property Owner(s): .y1Z�SZ+ . <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: C lr�i I <br />(Single Fa' 1. —Multi-Family—Com rcial—Government—Indzrstrial—Vacant—etc.) <br />Type of Building Construction: %�v(S�y �11•-�rt�l�t? <br />(6Vood Frame Br'ck-,Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape New ZReplacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />pp � f <br />Description of PropV <br />Work: �i""�l GL ( I 1 P --,.k `� lA~ <br />k,\(+:i�_0 ery v.rte_ CL_ �t- m� 'n :� r.LC j <- q <br />1. Q_ \Ac• 0r, nal re_SJto. CP <br />Owner/Contractor /x#- <br />/ <br />(Staff will correspo d w!llonl� one designee) <br />X 1 <br />Signatur Wher <br />e-mail: <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />