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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />x 1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE1) USE ONLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX-OFFICE USE ONLY <br />Date Received: J i l Application Number: in � " , — n s <br />Past Reviews: YES (Date of Last Review) ❑ NO v <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Title: <br />❑ Local Landmark �ocal Historic District (Name) <br />❑ National Landmark❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) � y� <br />Address of Property for proposed work: --�` �:.�j V �C/ <br />(Street Number— Street Name—City—Zip Code) <br />9 ( � <br />Name of Property Owner(s): ` V ii h V V QA, Phone #: "1 ' , Ltd— <br />Address of Property Owner(s): <br />Name of Contractor(s): I� <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: 511 in <br />(Single <br />Type of Building Construction: <br />1 gr`ve,41 S�' tt <br />(Street Number— Streeet,Name—City—Zip Code) , ' <br />C�1! O 0 !�l Phone #: "Iq q <br />(Street Number—Street Name—City—Zip Code) <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 />pr!,A, ,� / <br />Description of Proposed Work- i l nl G � � �� Vl VZ/ N"', VLA "J-4 <br />- <br />.,t� ij 1- 1 rib. <br />Owner/Contractor Fax #: e-mail: <br />(Staff• ill corres and wit my one designee) <br />Xq and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />