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Application <br />-FOR- <br />Certificate <br />FOR-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.stjosephcountyindiana.com/departments/SJCB P/index.htm <br />f: 574-235-9578 e: <br />,IYI.I,...IL I II„ 111 hd „, II p. 5 ,1 1 . gA 11 .11 P '.. HENTRIES CON AINED> TiiI�BOX«<«p llll 1, IY IYII Y, "i <br />OFFICE USE O(NLY> O E USE ONLY <br />Date Received: 9/37( 2016 Application Number: 30JU — 0937 <br />Past Reviews: YES (hare ofLast Review) 3 009 - O b i i ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: �r <br />❑ Local LandmarkLocal Historic District (Name) E-04WOAP iltt eP <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled F1Sent To Committee ❑ Approved and issued: <br />'IIY.iI..d.unJll.u.II...Id, Y Iii I., ,I Y "AY I- H. nYl.1 III'.IIIlYil.I...;I Milli I.IJII.unJiIIld.IY "k, 111 i.. ".I 1.11IIIli111. I.,,I"I'll.iulnu illuYIIIIIiiJaodl, lnlleY inlnli. nliiIIIII.iIInI ISI Ilin.illli•.inl �I .II�.il11.ul.�ii.ulllll.J <br />(Please Print) <br />Address of Property for proposed work: (, ? n t5 j_(.t 1 ikYt\.1 6 r, <br />(Street Number Street Name—City—Zip Code) <br />Hume of Property Owner(s): i-Lf:�G` J-- L IN( h A %_ NaLt`s LOS Lj Phone #: 5Z' { -S12 <br />Udress of Property Owner(s): 15 ZO 61 t l o IvYNt_� PiC= qp> C? <br />(Street Number Street Name--City—Zip Code) <br />Name of Contractor(s): P—qc t x i I_.A 0 M Phone #: -i.�/ - �-i"1 ' 0 %zq <br />Contract Company Name: �.1 A5T73M t� l l-t"�4CS#� I _ t 11 / 1�.� INC ' <br />Address of Contract Company; (��c�C?(,.,� <br />(Street Number Street Name—City—Zip Code) <br />Current Use of Building: 153 f 1,Q1 C I A, M i I <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant--etc.) <br />Type of Building Construction: I x -) C-1 c) it S A R k�?"., / '� I Ar T;E� Fn 0 F <br />(Wood Frame Bri,(k--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 />Description of Proposed Work: <br />-fit 1 ;oS j /'.1)1-r TD T-�f T:�> r ,I A 211 T"f=� -P 5 11.L <br />iiiiiivner/Contractor Fax #: <br />aff will correspond with only one designee) <br />Sign re of Owner <br />1 ..• <br />e-mail: r,(.AS t�M'O(,t_T"bOO12 1-1 V / t`...t & <br />and/or X <br />Signature of Contractor <br />B T:r_b — <br />�6 coI)Fw <br />