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1 <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://wwNv.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephAn.us <br />OFFICE USE ONLY- --DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: <br />Application Number: 020/$ <br />Past Reviews: <br />YES (Date of Last Review) <br />❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: / M qy ZOt_r <br />❑ Local LandmarkITLocal Historic District (Name) Csfff f�/k �q� K <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) c � ` /� % <br />Address of Property for proposed work: C) q ei J 1 J I A4 6 (9 l <br />i (Stre�ttmber— Street Name—City—Zip Code) <br />Name of Property Owner(s): t iA o sU Nl A ;4 01/x% I YAK Phone #: <br />Address of Property Owner(s): V(J 7 1E S I t <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />Type of Building Construction <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />(Single FamZly—Multi-Family—Commercial—Government Indztstrial—Vacant—etc.) <br />L,�G rl r) R A IV, <br />flood 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 />Descri tion of Proposed Work: _j&o or, " ��_ ��� Il�%��%�� r <br />�. <br />Owner/Contractor Fax #: e-mail: L r-_��� j' / U� [� t <br />(Staff willc6irespond tivith only one designee) --�" <br />X -- -- and/or X <br />Sig ature (Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />