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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 />htip: / /www.stj osephcountyindiana .com/departments /SJCHP /index.htm <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />., <br />OFFICE USE O n NL - Y» » »DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX« «« OFFICE ONL <br />LY <br />Date Received: ' (�Ul L0 Application Number: � 1t o _ O � l� 1 1) <br />Past Reviews: ® YES (Date of Last Review) 0 181 30 (d ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ <br />Local Landmark <br />Local Historic District (Name) W Ca,5� <br />U39, e h 1Z <br />❑ <br />National Landmark <br />❑ National Register District (Name) <br />, <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />.,,,,.., ., .,,,,,, ,,,,,,,,,,,,,,, ,,, .. .... .... ... . , ..,. <br />(Please Print) r fo �, C <br />Address of Property for proposed work: / / �/� (� <br />(Street Number— Stet Name — City —Zip Code) <br />(Street Number— Street Name —City —Zip Code) G� / <br />Name ofContractor(s): >111(_�1�7 �� (()/r`�u,� t�°� -�' Phone #:' - �� /[ <br />Name of Property Owner(s): 1AM (h /wA_ Phone #: __S7T ­ c:� ;;/ <br />Address of Property Owner(s): `711 l _ 37-1 7 <br />Contract Company Named/ <br />Address of Contract Company: ` �l y Y o(Z kS S / gL r l ,v rQS, / / Z <br />(Street Number—Street Name — City —Zip Code) t�(�� <br />Current Use of Building: <br />(Singlee Family— Multi - Family — Commercial— Governmmen / t— Industrial —V Vacant —etc.) <br />Type of Building Construction: 41u�'1 m ( n � / c r 7 l 7 �"/ <br />(Wood Frame Brick-- StoneBYeel— Concrete— Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape F--,New ❑ Replacement (not in -kind ❑ Demolition <br />(more than one box may be checked <br />Description of Proposed Work: t /? t / <br />Ow 7fwner Fax #: / e -mail: <br />( aff d wit n1y o esignee) <br />&/2 and /or X <br />Signa Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />