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r <br />Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />x 1865 R of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLYS»»>DO NOT CONffLETE ANY ENTRIES CONTAINED IN THIS BOX—OFFICE USE ONLY <br />Date Received: ®' Application Number: '( o' co _ —� o d <br />_Past Reviews: Er YES (Date of Last Review) 1 1 ' ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Title: <br />L V Local Historic District (Name) C_1 1N ,%�i(a <br />National Register District (Name) kt <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print)-� <br />Address of Property for proposed work: ®-� �Pi� f�'� �f31��� ✓Z107. e�� `6 <br />//�� / <br />(Street Number— Stre t Name—City—Zip Code) t <br />Name of Property Owner(s): // 6Zs-sl ?/l _„�i...rJJ _' Phone #: <br />Address of Property Owner(s): I-RDJ 'A1129- <br />(S_treeeett Kuumber— Street Name—City—Zip Code) <br />Name of Contractor(s): .e%C .G, S S;P -�7` �G�CZ3 Phone #: 4 <br />/��'1 <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />Type of Building Construction: <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind Q Landscape ❑ New ❑ Replacement (not in-kind ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: /c .v/vrc-. p ��. rrrrp-S �,sfl�•,�i%�iY�,i�l nr� �� <br />zf-psi7 <br />a V <br />AJ A/X.; �x <br />Owner/Contractor Fax #: e-mail: 1"a -C co, ani /, C av-7 <br />(Staff will correspo with o e designee) <br />X and/or X <br />Signa ure of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />