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Application <br />-FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COAMSSION <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: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE ONLYS » » >DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX« ««OFFICE USE ONLY <br />Date Received: J ((� , a� Application Number: <br />Past Reviews: ® YES (Dare ofLast Rewew) �I f 11 �� X, @01G ❑ NO <br />Staff Approval authorized by: � Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ® Local Historic District (Name) I Jf1�id� <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />El Sent ❑Tabled F] Denied To Committee . [] Approved and issued: <br />(Please Print) t \ <br />Address of Property for proposed work: 1-C) to t/ (IS. ? tJi' S ou 1 !l F nd, 1 LIle <br />r� (StreetNumber— StreetName— City —Zip Code) <br />Name of Property Owner(s): Phone #: 7`r' �(S q - ��0I O <br />Address of Property Owner(s): 10 Lo 9 : < J 6f S i a E ?) 0 n j 3 7 - - t 6 U U (- l Lo <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): A k w' n s F v e <r vc,4i vu, <br />` .J <br />Contract Company Name: <br />Phone #: <br />Address of Contract Company: <br />(Street Number Street Name­–City—Zip Code) <br />Current Use of Building: S ,k tlgl P_ rU (Y) ! `/ <br />(Si gle Family — Multi - Family -- Commercial --- Government Industrial — Vacant —etc.) <br />Type of Building Construction: vio04 tr'GI o- <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Proposed Work: 0 In -Kind Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: CC MA a o - \ e ck <br />Owner /Contractor Fax #: e kalaa UAo0. P am <br />(Staff will correspond with only one designee) <br />and /or X <br />Signature of Owner �� Signature of Contractor <br />