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Application <br />-FOR- <br />Certificate <br />FOR- <br />Certi icate 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/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLYr»»»DO NOT COMPLETE ANY ENTRIES CONTAINED fI.N THIS BOX --<<OFFICE USE ONLY <br />Date Received: I l ab I III Application Number: <br />Past Reviews: � YES (Date of Last Review) �!� (� I a�0(p ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />- MV Local Landmark <br />❑ Local Historic District (Name) <br />❑ National Landmark <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />_ ❑Denied ❑Tabled <br />❑Sent To Committee ❑Approved and issued: <br />(Please Print) 57b 4 �S 1 � ✓,, - I � - �O (, � ➢ [ �(F 'j <br />Address of Property for proposed work: � • ui-v� � I J <br />rr-•, +� (Street Number : Street Name—City—Zip Code) <br />Name of Property Owner(s): 1 �t. LoWp-1 I `gobjA�s L L Phone #: - 1 •O Z <br />Address of Property Owner(s): 3401-7 / e K.-{ V�1 I P - V 400-1 �� D ► + (Q� <br />� <br />(�Street�Ifumber— Street Name—City—Zip Code) ` l' <br />Name of Contractor(s): if 1 � ,.,, `^ I V 1 -D <br />E5 i&AS 6- LI.. � phone #: �7� . 7 3 �• �� 1 <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building:1� <br />(Single Family—Multi-Family--C`oml mercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: Fri b4Cl�t ` SO � P-i(4L W �j% �L�1`k ( /� CA -DE <br />11 ( (Wood Frannie Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ADemolition <br />(more than one box may be checked) <br />tt-A-n <br />criptionofProposedWork:l'/>1=M.L-01` of �►a0O `5&, f+ �VIt-1D1144 WR(644 L}•S Mol <br />© F e" 1,t NA -L (i s l"0 2i (- 5—IQ-0 L -L) ILE , 130 ( L -D 1 t 15 M6-1 -5&We,0 wink <br />t V, I j+ias ..46A Miz- 1-49ft0� . V0iL,0i;tUf C04�1V BSEP 4S CoSioKA�yE .'i-l+r . <br />Weot)rg XoP i s vET�►o�11�0 AOo 0JI�0;A q s &F W *(P Nd. JA -10E .Cz) AM ��T 11,ftw <br />OF AMP,, ISO I•f of 40AtMC0LIA4» �A408 OWt4E►�4t, ► W&11y.)Af FFa4 Ohl orl/' �5r coR. ek <br />Owner/Contra or Fax #: e-mail: QN r t �° 0-d (` a I i'1 C) Z•D M <br />(Staff will cor es on ►th onl n desi ee) <br />X �/�- and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />