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Application <br />.�' 1 1 -FOR- <br />PEACE <br />FOR - sa <br />1 j d Certificate of Appropriateness m <br />O w <br />PEACE/j �, K <br />;R a HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj os ephcountyindiana.com/departments/SJCB P/index.httn <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />ii,.n.i.l„..i, nil.. <br />OFFICE USE ONLY>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received:O �Ui) c2( -5/,j Application Number: OW 45 — Q '�Q 2 <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 />ITLocal Historic District (Name) <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied❑ Tabled ElSent To Committee ❑ Approved and issued: <br />(Please Print) L@Address of Property for proposed work:�/_/ 1jf,�f►'" s � <br />(Street Number— Street tame—City-Zip Cod }� <br />Name of Property Owner(s): Phone <br />Address of Property Owner(s): <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): 1f C.t �/%I i'L[�// Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number—Street Name—City—Zip Code) <br />Current Use of Building: <br />Ingle FamilMulti-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: `C�L� .11 j 1_-1 <br />GYood FramelBrick 'Stone—Steel—Concrete—Other) <br />i <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked <br />Descri tion of Propos d Work: <br />s� 7 J<- <br />Owner/Contractor Fax #: <br />(Sta ff cespon with only one d&ignee) <br />Signs ru a of Owner <br />e-mail: <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />