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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.stj osephcountyindiana .com/departments /SJCB P /index.htm <br />p: 574- 235 -9798 f: 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY - >> > NOT COMPLETE ANY ENTRIES CONTAINED t IN ,, THIS BOX « « « USE ONLY <br />Date Received: 1 (AV�j t�' Application Number: / � 1 U — 1 <br />Past Reviews: EYES (Date ofLartReview) ❑ NO <br />Staff Approval authorized by: . Title: <br />Historic Preservation Commission Review Date:, 9 n lS/ <br />❑ Local Landmark Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) ` <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) I � <br />Address of Property for proposed work: Da S S un n uj� Ir ���Q <br />(Street Number — treet Name — City --Zip Code) . <br />Name of Property Owner(s): ( � ��� (�� � � Phone #: 5 <br />Address of Property Owner(s): 1 ��, (� i "(J`C, <br />*(SeWetNbStreet Name — City —Zip Code) <br />Name of Contractor(s): � 5 Phone <br />Contract Company Name: <br />Address of Contract Company: V <br />C (Street Number — Street Name — City —Zip Code) <br />Current Use of Building: [ L Jtni bU-.4 <br />(Single Family — Multi - Family — Commercial— Government— Inditstrial— Vacant —ete.) <br />Type of Building Construction: ( nd cu �<� <br />(Wood Frame <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) ]j <br />Description of Proposed Work: _ ,Ll (J (�i I1-J <br />Owner /Contractor Fax #: 5& e -mail: � �� � 6D <br />(Staff will correspond with only one designee) <br />X and/or C <br />Signature of Owner SignatLED ont actor <br />APPLICATION REQUIREMENTS ARE LIS N INNERS SID <br />