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Application `001AISSIO/V <br />- FOR - <br />Certificate of Appropriateness <br />01. HISTORIC PRESERVATION COMMISSION `oma " o� <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125S Lafayette Blvd., South Bend, M 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONL Y5»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 3 Waw- o20115 Application Number: 01615 : — 4303,4 <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 />�NO <br />Title: <br />' lla i1�,2o2O/S . <br />cal Historic District (Name) <br />©"Lo <br />National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledE]Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: l / W. M AD I S N, 5 0 0 &ZIL, <br />(Street Number—Street ame—City—Zip Code) <br />Name of Property Owner(s): M Phone #: <br />Address of Property Owner(s): '7)a 13oA 111,42 4� ^ /P 4U v <br />(Street Number— Street Name—City—Zip Code) <br />�. P)Phone #: �+ 0--ftName of Contractors <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building:�%�����L ��M L�P <br />(Single Family—Multt-Family—Commercial—Government Industrial—Vacant—etc.) <br />Type of Building Construction: <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:o 4.1 f 1 a W or H # 1f se k H *D G'j 412 t4ej � <br />Owner/Comet acto Fax #: f90- 24)5- 0 e-mail: TZ �ji L w r-- rt Sao A c O�U)3 I v <br />(Staff will torr and with only one de;.ignee) V <br />I <br />_��% -- and/or X <br />Sign tore of Owner Signature of Contractor <br />I <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />