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Application <br />` "P/2 -FOR- <br />Certificate of Appropriateness <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 /SJCBP /index.ht n <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE ONLYy » » >DO T <br />NOT COMPLEE 'I E <br />' ' I ANY ENTRIES CONTAINED IN THIS BOX « «< OFFICE USE ONLY <br />r7 t a < <br />Date Received: I"114q' A ` (o Application Number: 706 — � () (�_ <br />Past Reviews: 9 YES (Date of Last Review) ❑ NO <br />(Please Print) 2 Mn <br />Address of Property for proposed work: 32 ��� Q �� 6 r vl <br />(Street Number— Street Name —City —Zip Code) t� �f (j <br />Name of Property Owner(s): DE I V hone #: S 77 CA �� ` 0 <br />Address of Property Owner(s): - ,� 4/ , C k ( `/' : , �I�Aw d � '5 32--'?09q <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) V" ►mot c , <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee F] Approved and issued: <br />Contract Company Name: �Q I- - <br />n - (Street Number— Street7Vame— City =Zip Code) - � <br />Name of Contractor(s): � 4U L- U 2 Phone #: c� + G VL+�C n <br />Address of Contract Company: ' <br />(Street Number— Street Name —City —Zip Code) <br />Current Use of Building: „) %.` GGA� l P ? , 1 \ <br />(Single FAily-Multi- Family— �Cor?mercial— Government— Industrial- <br />Description of Pr posed Work: R-Q� e. " &+- r0 O C ir✓' 1 ` W ' t 1, <br />Pd` < Q+" t? 1 <br />Type of Building Construction: Woo iP Pto wt <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: In -Kind ❑ Landscape Ix New ❑ Replacement (not in -kind ❑ Demolition <br />(more than one box ma be checked) <br />`rte. 1nA — KA <br />i <br />A S 0--MA (70'✓ s Ma r t <br />Owner /Contractor Fax #: a -mail: <br />(Sta or nd w* 1 one des <br />X / and /or <br />Signature of Owner <br />$Q d V <br />lo <br />v �© - <br />X -1.. 1/ �f 11AL. �,l <br />Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />