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r <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />�t HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />x is6s 125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj o sephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />•OFFS'�C(E�'USE ONLY»»»DO NOT CONWLETE ANY ENTRIES CONTAINED IN TIIIS BOX«««OFFICE USE ONLY 111111' ." " <br />Date Received: Ali V1 Application Number: � Ll <br />Past Reviews: CllfYES (Date of Last Review) p ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />;n 1 Title: <br />Local Historic District (Name) L Vl j <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee F1Approved and issued: <br />„ .. . .... ....... <br />(Please Print) r' � �' t� -C.0 A ("'6 ~ <br />Address of Property for proposed work: � �-- � � � � "' '' �v -. � f 4 r.►CS <br />(Streit Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): JOS �i. ic„ t _ ` its Phone #: q03 5 - <br />Address of Property Owner(s): 2-1 ' tt e,,.e-- 5�-5; SCb11;ft, 6e"!..X, E0 <br />(Street Number= Street Name—Cit)--Zip Code) <br />Name of Contractor(s): t G Ci ftiv� C�wG Q r <br />Contract Company Name: <br />Phone #: <br />Address of Contract Company: f7 f 3" C � �. % � t'7" r- "-,�'% {ei 14-7- 0 <br />(Street Number -Street Name—Cit J Zip Code) <br />Current Use of Building:' <br />sic iw <br />(tingle Family -Muyi-Family-Commercial—Government—Inditstrial—Vacant—etc.) <br />Type of Building Construction: tr✓ cICrG('x'a-t P j� � <br />(Wood Fame 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 />Description of Proposed Work:e� <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />Signa re of caner <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />� i t,.xaC�-•� �.�.sC.Z ^ c�.:e? - � f J a � �%�)-ter// <br />e-mail: �! C05f�C�.��/� iA c E'v✓1 <br />andloriX <br />Signature of Contractor <br />