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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://www.stjosephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.st-joseph.in.us <br />rein l .111. nnw lue11 iii ilii. n.11 el 11..111 de 1 1 . 11 1111 1 1 11 .1 111 . .1 111 11 . .1 1111 . i 1 . uu 1. 1.tli eu111 1 . ii 1111I'll 1111 nn Lu1 1 1 <br />OFFICE USE O1VLiS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 7 nuxp, c,10 j- Application Number: 0ZU I0 — ©0 0,5k <br />U <br />Past Reviews: 2YES (DateofLaslRM—)15 �� — ❑ NO <br />I <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />BLocal Landmark ❑ Local Historic District (1vame) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />I. 1.:.. 11111, . 1. 1 1...1.1...1,1,:.,.,1.11.11,.,1,111., .1...1.. ....11.11.1.111 ..1..0.... .11................,..11e1.:.. „11...,1.,........11111, .1...1.1.1.1..111.0 ..® <br />(Please Print) ,, / <br />Address of Property for proposed work: �e2s�(I&Ireet <br />j�o erc_� ,10P.tia�.v Y�ol/y <br />" umber—StreetName—City—Zip Code) <br />Name of Property Owner(s): oI le, a,.� Al A /mow Phone #: S 7y` -11-el <br />Address of Property Owner(s): 6 O -717 /< -, _,a w't ;pv-1 l 2:-� e,- l <br />n / (StreetNumber—StreetName—City—Zip Code) <br />Name of Contractor(s): l Si l� v Ss w Phone #: a403 qy'�9TSr,- <br />Contract Company Name: ltJ.Nr a�.e� /{SSMC <br />Address of Contract Company: <br />(Street Num <br />/ber— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single FamiZ Multi Family—Co mercial--Crovernment—Industrial—Vacant—etc.) <br />Type of Building Construction: ! G A, Ae;,, k, ,t e — j &,Y -k <br />(W6od Frame—Brick--Stone--Steel—Concrete—Other) <br />Proposed Work:In-Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box maybe checked) <br />Description of Proposed Work: Ve, <br />z <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X �� - and/or X <br />Signature of Owner Signature of Contractor <br />