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Application <br />-FOR- <br />A r F <br />FOR-ACFCertificate ofAppropriateness 6 <br />HISTORIC PRESERVATION COMMISSION 0' 7' cow <br />x 1865 R of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osephcountyindiana.com/departments/SJCHP/index.httn <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY 1" j1 11 „ <br />Date Received: t "20 Is- Application Number: <br />Past Reviews: L r I IES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Title: <br />/.Jr t e, 2O15 <br />Local Historic District (Name) <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To CommitteeElApproved and issued: <br />(Please Print) 'Z 2 S W e c �' / �O vim[ 14, <br />Address of Property for proposed work: > goy -414 S� Q � r? !� (- <br />(Street Number— Street Name—City—Zip Code) L� / 7 <br />Name of Property Owner(s): "I-)RU& LA) b-9 (:jA1t4 �)Ei %REZ Phone #: S7y 53a — ge S,03 <br />Address of Property Owner(s): 17qf y gUGZ,�L 410,��.. (7 g V1_,Fe <br />T (Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): I �J 3 Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />c(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: ✓ v1 Fet t111 / ( <br />(Sing Fami y-Multi-Family—Commercial—Government—Industrial- <br />Type of Building Construction: wood FM M �P <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work:In-Kind E]Landscape❑ New 0 Replacement (not in E]Demolition <br />(more than one box may e checked <br />Description of Proposed Work: e vt4 (J V e <br />r) r 1, of ) v\ 6k e (CA ,n �� rA T-- (i <br />A r+) r` I /,1 f /.i <br />A l u llv i •vu v+A s Y-0 /-74A,w • o L(jS _(AJ t � \A <br />Owner/Contractor ax e-mail: <br />(Staff will correspond with only one design e) <br />X /Jcu� _V <br />Sign <br />atule of Owner <br />M l u 11!1 t 11 t) KA S ;,e 1 0 Gi- 0061 <br />J�,,,,(,or-nlcm a"11\I __ 41- <br />e <br />('e s loe-to <br />C n y= T'• I`C <br />o'Y'i e <br />41 - rIx I <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />