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1/ <br />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-josephJn.us <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY ENTRIES CONTAINED O <br />' 1 D IN THIS BOX« «« FFICE USE O1VL Y <br />Date Received: 9_71\11AI W Application Number: VAU —'0 <br />Past Reviews: YES (Date of Last Review) MW d, ROM ❑ NO <br />) <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: phrA I S I 2 01 W <br />❑ Local Landmark Local Historic District (Name) l�(l A� I h e CA 1 C` C ' <br />❑ National Landmark National Register District (Name) Cl �aV\ h 1 a r k <br />Certificate of Appropriateness: 1 <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />Current Use of Building: <br />(Single Family— M�u - Family - Commercial — Government — Industrial— Vacant —etc.) <br />Type of Building Construction: 1' �� t►1 <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 <br />(Please Print) . „.,, „..,.,.,,,,Q,,,.� v „�.,,.,. 1 . ,4"6 ,6,,,1 <br />Address of Property for proposed work: /► <br />(Street Number—Street Name—City —Zip Code) <br />Name of Property Owner(s): 6( J�1(� 1,1 W 0 Phone #: <br />Address of Property Owner(s): S l�tiw -WS ABO VE— <br />(Street Number — Street Name — City —Zip Code) <br />n �f - f <br />Name of Contractor(s): ( j f Phone #: `� �"I `� � �� <br />Contractor Company Name: C' s )( nr C m t� �� <br />Address of Contractor Company: I p�aUN�� Vl* RL'A ' A 4 6� <br />(Street Number— Street Name — City —Zip Code) <br />Description of Proposed Work: <br />Owner /Contractor Fax #: 5 )) 4 - 2 13 T. 9 9 03e -mail: <br />■ <br />$4 <br />X and /or X � hq�• <br />Signature of Owner Signature of ntractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />