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Application `00„,►ss1a&f�s <br />- FOR - s� <br />Certificate of Appropriateness <br />z <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY may! �1e <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-josephJn.us <br />OFFICE <br />USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY = <br />Date Received: rf- / 'w !S Application Number. or?d!S <br />u = <br />Past Reviews: FR --YES (vale ojLarlBevtew) r�o2 �❑ NO = <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Title: <br />ID <br />Local Historic District (Name) <br />U <br />❑ National Register District(Nan,e) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) c <br />Address of Property for proposed work: • &%nn_ti s it: <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): URAL A14 '” t 0 &Aser Phone #: <br />Address of PropertyOwner(s): Sol rj. 50NOIJSIDi: AVE., sok-rH (310WD,W J/bhls' <br />(Street Number— Street Name—City—Zip Code) <br />p�.G�-trF�f <br />Name of fuu=acw-t9): KF 1///f Phone #: <br />Contract Company Name: A -T0 ►7 ESifs/1� �-�-C I'cC����,( 1 U <br />Address of Contract Company: J � G EO$1 la � I 1e (Si • v8►��k ti`�'i 1 N -16 b n' <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: .SP41'r FAMILY <br />(Single Fainil)—Multi-Family—Commercial—Government Industrial—Vacant—etc.) <br />Type of Building Construction: P/00 D fR-AMF1 f3AI Ck `f_61011E vpljve�la'6� <br />(Wood Frame Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: Q In -Kind ❑Landscape ❑ New E]Replacement(not in-kind) E] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: IVlDig hix !'AllpiTIONlac, CONDF-NSFRs (z) ?O 1:145AZ W&D, <br />Ft-,kT ROOF. 91,46LOS5 FLAT kooF tlll-rH R Pfr1N7ED WOOD1+011 A.EflCbc ('CVST6A4) <br />TO InkTCFI TRIM OF 7-Nt !HOME, Wfile-9 WILL 'THF <br />GoNPEn/si;,�S <br />Owner/Contractor Fax M e-mail: <br />(Staff will co pond with on one designee) <br />X and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />