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Application <br />-FOR- <br />Ceyt jeate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />x 1865 of SOUTH BEND & ST. JOSEPH COUNTY <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-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««pOFF/ICE USE ONLY <br />Date Received: (p o2D�Jr Application Number: Ot4lS <br />_Past Reviews: ❑ YES (DateoJLastReview) ®/NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: /,S <br />❑ Local Landmark Local Historic District (Nan:e).L!/tuy �O <br />National Register District (Name) <br />El National Landmark El o <br />Certificate of Appropriateness: <br />❑ DeniedElTabled El To Committee ElApproved and issued: <br />(Please Print) _ j <br />Address of Property for proposed work: `J OTUWJR G- ���1 ` i 'e l� �t (.n ' <br />(Street Number— Street Name—City—Zi Code) <br />Name of Property Owner(s): LY2F,,%1 GjjTEiL►�e 1� t✓F rN tEhone #: a.S <br />Address of Property Owner(s): Qom- _Fq_�,tD1 St�ii>r lat0S i sJL,, <br />(Street Namaber— Street Name—City--Zip Code) <br />Name of Contractor(s): TIb1-) Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: �PtCli� A76� <br />(Single Family—Matlti-Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: <br />(Wood 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) 9 <br />Description of Proposed Work:rte_1 i 1_t'�.1 C35F Nt '6�' ?I-NPr Ca _E5-AG1tT" C—Li 1, 11ti_�tt om! <br />of , % e5 "1ZT`I 11fln, Ptt l mcnJ i . <br />Owner/Contractor Fax #: <br />(Staff wi orrespon with ly one de��(ignee) <br />Signature Owner a <br />e-mail:i�c/Pf�SoGC?�'1�1d/t'1 <br />/ 6 <br />and/or X <br />Signature of Contractor <br />