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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY>»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />= Date Received: 43 - 03 - o?O/s <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Application Number: o201,5 <br />Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ NO <br />Title: <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work:�lg <br />,�; (Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): ,E D % 7-E � D jr1-� Phone #: <br />Address of Property Owner(s): r 6Z, 1.1D1-iGx A Pf• 5-f //y <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): ,�j %` 4111 -AY <br />Contract Company Name: <br />Address of Contract Company: <br />4Gl� w <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: 6,11-1<kie a N I - 14p'v 5c --- <br />(Single Family—Multi-Family—Commercial—Government Industrial—Vacant—etc) <br />Type of Building Construction: fGtr?%} <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 />Description of Proposed Work: Zrm,a/iG V if 14 a f f �10ee- <br />Owner/Contra•e Fax#: P741 ?t 5` ?Q63 e-mail: P Wi i, if 6Aft 0eU'0 YN . <br />(Staff ivill corresp d with only one designee) <br />f��--- and/or X <br />Si ature St Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />