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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125S Lafayette Blvd., South Bend, IN A44ni <br />http://www.stj osephcountyindiana.com/departments/SJCB P/index.httn <br />p: 574-235-9798 f. 574-235-9578 . e: SBSJCH?C@co.st-josephJn.us <br />OFFICE USE ONLY— ­—DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: na,6z e. a04T <br />Past Reviews: BYES (Date gfLast Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Local Landmark <br />National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Application Number: <br />❑ NO <br />Title: <br />820 4.5 <br />❑ Local Historic District (Name) �� <br />t� National Register District (Name) �� Ae Z L <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) NO ,��II //-- _rr ��11�� l/ <br />Address of Property for proposed work: w 5�& Lim e.��+e tvl 7'�cul'1� �u� 6��1n VIVI iS) Tlo6O41 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): 150lik �%��� dt, P�►��SLL � pPhone #: 23.5— q- �-o <br />Address of Property Owner(s): 3 2 ` S PRT°��°tw1 P e4l- % q 6 ('0 d -[ <br />�n n (Street Num <br />mbber— Street Name—City—Zip Code) �r <br />Name of Contractor(s): 1 '` o. c!l,�T �i o A PPI Ilv a v"� O��V `DUD KaA'zr(v'Phone#• 2 g 'j <br />Contract Company Name: Sas`�"t� �p�^v'^�`'Lwk J ��001 l:ar� �� �(f •JQ•I Chi C'o ��-ba�Q ► �d� <br />Address of Contract Company: Z 4 54—T&5 5'r. S&LJk 8 �eAU <br />(Street Number— Street Name—City—Zip Code). <br />Current Use of Building: F&A-L 0 P 2,, s P0.,G�, <br />(Single Family, Multti-Famiby—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: N ©� 1'6 pe (1-" �61 <br />(Wood Frame Brick—Stone—Steel—Concrete—Other) <br />ProposedWork: ❑ In -Kind © Landscape ❑ New ❑ Replacement (not in -king ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: t4d k D S ®✓k eU4" n.1 c^ C dm_eC w1 J ct,t`t <br />---D f' Vt� P�z�.fa(" �-�.n t.,I p a evt-,& 15 g — e- PY-v G 'i' e� a, (,b inC� �� P� vfiu Ike <br />Uj <br />P v\. vl o q \ 0" Q n. a ,rG `� dr�..,� 5 o wk� w of '� dz kme,- o ' '�"eh`l S Couv i. <br />Gctly ©t�p� u S '� Z s esvi`c,e pro `P�`t l o.�n VL� v (_ <br />Owner/Contractor Fax #: rr�,Pr�����e e-mail: v <br />(Staff will <br />correspond wi h only one dessiigneej) h nn <br />X , q; i 1 4�KS and/or X '/A{ ���`(" t�� I`►�f � yl <br />a r <br />Signature of Owner C s era ekiP. a,ia. zqc py� Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />