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application <br />- FOR - <br />Certificate ofAppropriatenesso <br />V <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY Hyl rya <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONL>>>>>>D0 NOT CONTLETE ANY ENTRIES CONTAINED IN THIS B0X<<<<<<OFF10E USE ONLY <br />Date Received: QIT A44 .020 L.5' <br />Past Reviews: Z YES (Date of Last' Review) <br />1 Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />El Local Landmark <br />F1 National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Application Number: C10/,5- <br />FINO <br />Title: <br />'12taq 2045 <br />IJP <br />Local Historic District (Name) *aw 4XW, <br />❑ National Register District (Name) <br />F❑ Sent To Committee ❑ Approved and issued: <br />Id <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Number— Street Name—City—Zip Code) <br />Phone #: <br />Name of Property Owner(s): k lz� '?"W2,7 <br />Address of Property Owner(s): <br />(Street Number— Street Name—City—Zip Code) <br />()Rh o n e #:Name of Contractors <br />Contract Company Name: � <br />_o -e <br />-&-VVD'7 j/'0/ <br />i" <br />h 4 vev� t5 <br />is wivo"IAW- <br />Address of Contract Company: <br />(Street Number— Street Name—City--Zip Code). <br />Current Use of Building: <br />(Single Family—Multi-Famil)?---Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Replacement (not in-kind) ❑ Demolition <br />Proposed Work: ❑ In-KindEl"Landscape 2 --Ne. <br />(more than one box may be checked) <br />Description of Proposed Work: <br />2jj)—O,j 9 ilc?? • XqAb CO—, t Ile& <br />ktr&,C6 4 <br />Aoll <br />I <br />Owner/Contractor Fax #: 89 e-mail: (t, ri'.c7rl tVP Clip 'ifi? �00 - if 6 tO. <br />(StaffA correspond with only one designee) k/ j <br />X � ]/14- - //U ///[// �' M IVY' - and/or X <br />e of Owner <br />SignSignature of Contractor <br />at <br />I —APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />