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Application <br />FOR - <br />�� , Certificate of Appropriateness <br />\\ PEACE <br />HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http: / /www.stjosephcountyindiana .com/departments /SJCHP /index.htin <br />p: 574- 235 -9798 f 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLn » » >DO NOT COMPLETE ANY ENTRIES CONTAINED IN TffiSB „1 " ' " <br />OX « « «OFFI <br />/ r CE USE ONLY <br />'7 <br />Date Received: I I )q -1 11, Application Number: 30 — ON <br />Past Reviews: ❑ YES (Date of Last Review) © NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ® Local Historic District (Name) l _h0l),11 ' POIL <br />❑ National Landmark Pq National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑Sent To Committee ❑Approved and issued: <br />... ....e..,..,., .,:,.. ..,....,..:.,.., ....,.,....,, „.,.,.. .............. <br />(Please Print) lit ( <br />Address of Property for proposed work: &" <br />(Street Number— Street Name — City —Zip Code) <br />Name of Property Owner(s): Phone #: <br />e; s <br />Address of Property Owner(s): of v � <br />(Street Number— Street Name — City—Zip Code) <br />Name of Contractor(s): Ph <br />1 �" "'� one #: 0 <br />Contract Company Name: PUP ityG n . ��� ���5 °� l – ye <br />yy!! p� O da'Y Iu \ ✓2m -> <br />Address of Contract Company: El"; <br />(Street Number— Street Name —City —Zip Code) <br />wul Current Use of Building: k %' <br />(Single Family — Multi- Family — Commercial — Government Indatstrial— Vacant —etc.) <br />Type of Building Construction: 7 �° <br />(Wood Frame — Brick — Stone — Steel— Concrete— Other) <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked) <br />Description of Proposed Work: <br />e m <br />❑ Landscape A New <br />❑ Replacement (not in -kind) ❑ Demolition <br />T O <br />Owner Contractor Fax #: a -mail: <br />6taff will correspond with only one designee) <br />and /or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />