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T,H Application <br />-FOR- <br />- Certificate of Appropriateness <br />`e x ":; 'a HISTORIC PRESERVATION CONMUSSION <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.htrn <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 IN THIS BOX«««OFF10E USE ONLY <br />Date Received /0 h Ito Application Number: <br />Past Reviews: BYES (Date ofL-R-L—) NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Title: <br />J 1IA% I� <br />p'ul �S�— �! oa �G• C� Q <br />Local Historic District (Name) pY <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) q d09:1179 <br />cc <br />Address of Property for proposed work: ! tJm d 0 9 1 9 J N ) ZG M I V lL� �a tllf 8EA)3 L16 61; <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): HA R2 1 LLEhI C `GoN AJ gi .L_ d- PCI -67 ,i A t1C-fZPhone #: 033 /olWR <br />Address of PropertyOwner(s): ha% Ol Ak),e 1t- 9110kC AA. S&cAk- Ae-NA 4961'7 <br />(Street N:meber— Street Nake—City—Zip Code) <br />Name of Contractor(s): ER L_j�E tj 1 L LC (. Phone #: <br />Contract Company Name: f L-1- L )r')C) A P M F l N C7 <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: S J NSI G L E r= Atl /L V - <br />(Single Familly—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: L J v o f` f fw e - <br />(Wood rame—Brick—Stone--Steel—Concrete—Other) <br />Proposed Work: ElIn-Kind ❑ Landscape ❑ New Replacement (not in-kind) ❑ Demolition <br />(more than one box may be chec61PCHOVe <br />Description of Proposed Work: A'L_U t1 N W(1 -t $1 A l lei G �i' k o 5 foiee- Ok l G 1N AL <br />1n)DOQ S 1IMNG 0- AGC P–PO&J i DDA- _07i1 <br />6PL(C A %j1 R trpN � 14- P N aLi) 0s ) <br />wner/ 7 ontractor Fax M <br />Will correspond with only one designee) <br />X <br />Signatur f76nr <br />e-mail: �a��/e>'�Pt� r�COr�H(?�>` P nd . -ed,, <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />