|
Application
<br />-FOR-
<br />R . �� ,,, c o
<br />��\ ''� d Certificate of Appropriateness
<br />� �R/� /� ti
<br />HISTORIC PRESERVATION COMMISSION
<br />1865 of SOUTH BEND & ST. JOSEPH COUNTY Hyl *tiac
<br />-- 125 S. Lafayette Blvd., South Bend, IN 46601
<br />http://www.stj osephcountyindiana.com/departments/SJCHP/index.htm
<br />1 p: 574-235-9798 " „ f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us
<br />DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BO OFFICE USE ON
<br />OFFICE USE ON7—h/20
<br />L�Y»»» X««« ONLY
<br />_
<br />Date Received: S '2 ! — //Application Number: 2016 — 09370
<br />Past Reviews: ❑ YES (Date of Last Review) a NO
<br />Staff Approval authorized by: Title:
<br />Historic Preservation Commission Review Date:
<br />❑ Local Landmark © /� Local Historic District (Name) t ��uffl &at+ Poty
<br />❑ National Landmark ® National Register District (Name)
<br />Certificate of Appropriateness:
<br />❑ Denied ❑Tabled ❑ Sent To Committee ❑ Approved and issued:
<br />(Please Print)...,,,,.....__,,,.•..._���...,,...',,.,.o��,,...�... ,•.,. „„....•..,...,,, „.,..,„,..,
<br />,.....,,,,,..•.,,•..,..,......, ,.,,. •,„ ..,.,....,.,„.,,_
<br />Address of Property for proposed work: l�/A v,,4 tt,
<br />�n(Street Number—Street Name—City—Zip Code)
<br />Name of Property Owner(s): ( l G_' V/! cr7G�� Phone #: 3//,, 933
<br />Address of Property Owner(s): L�v 'ate! 62 V�' !rt 5C7c21'41 16 e;,7
<br />(Street Number—Street Name—City—Zip Code)
<br />Name of Contractor(s): Dwc� �� Phone #:
<br />Contract Company Name:
<br />Address of Contract Company:
<br />f (Street Number— Street Name—City—Zip Code)
<br />Current Use of Building: 1 �Gt i�rl
<br />(Single milt'—Multi-Famil� mercial—Government—Industrial—Vacant—etc.)
<br />Type of Building Construction:
<br />(Wood Frame—Brick--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: 19\' 4#4l; moa `� d ;,� ; 4 A,
<br />V v
<br />Owner/Contractor Fax #: e-mail: C._..4/e n �5/1 /�01; �_ �o�►
<br />(Staff will correspond with only one designee)
<br />X and/or X
<br />Signature of Owner Signature of Contractor
<br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE—
<br />
|