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Applicati ®n <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 /SJCHP /index.htm <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY ENTRIES CONTA IN THIS BOX - OFFICE USE ONLY <br />Date Received: 3AYAarm �If Application Number: / — A ; I <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: W rl <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) <br />Address of Property for proposed work: <br />Name of Property Owner(s): <br />Address of Property Owner(s): <br />hweis ,0 <br />/13P �, <br />(Street Number— Street Name — City —Zip Code) <br />// /r <br />�r�0 e! /[� Phone #: 5 7V- .3��' 6D /o <br />Jfg��, �/ �� � ( /9r_ /7 <br />(Street Number— Street Name — City —Zip Code) <br />Name of Contractor(s): Q4 r i OL � j Q(` Phone #: .�7y j 3� Z <br />Contract Company Name: jrl nt h e-i er >9rj i <br />4 .1 1 1 <br />Address of Contract Company: %5 1AA3 / S o k D r. )AJ <br />(Stree$ Number— Street Name —City —Zip Code) <br />Current Use of Building: Jt hs-CP �+ -1' <br />(Single Family— Multi- Family — Commercial -- Government— Indztstrial— 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)n_ /� �F <br />Description of Proposed Work: Ad9P t ev/ sfi", �5 G-, Pr/ 7�v-p A '5 Ct T t c r <br />d ri the, W a-L, AQ ,O Z 5'�A ar,, ,.t Q , CcM*gcc i CaW rct-p &,o_ kcjfus 4 <br />�� ► �� � t <br />U (0- f i'L kyajeoq i vt, 0 W avla �Q t( e &-�U vcr' In AW 91Z <br />fMAL, I 9ib 4-re,�s C-A en-it'ai "5 r, ourCZ3 <br />{ n J <br />Owner /Contractor Fax #: e-mail: U 6L(l l ��d 7� ytuQC f C CYU - <br />(Staff will correspond with only one designee) (/ <br />X <br />Signature of Owner <br />and /or X <br />Signature of Contractor <br />