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Application <br />-FOR- <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMSSION °m o° <br />of SOUTH BEND & ST. JOSEPH COUNTY "'yf I ,.tic <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.st-joseph.in.us <br />i 1111 OFFICE USE ONL Y>>>—>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS fBOX«««OFFICE USE ONLY <br />Date Received: O un e a. D 0l G <br />Past Reviews: ® YES (DateofL-Rev&-) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Application Number. a 0 1 (D - 0 6 0 a <br />M4 R A19 NO <br />Title: <br />Local Historic District (Name) Caq� <br />❑ National Register District.(ivame) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) �� Q <br />Address of Property for proposed work: I �� �'e �-"'1 <br />(Street Number- Street Name -City --Zip Code) <br />Name ofPro a Owner(s): �GJh�er �'J3i^iz�laC��Cli-t-ll� <br />Property y Phone #: off- 5y Co3 <br />Address of Property Owner(s): w6w rit 0'+✓ <br />(Street Number- Street Name -City -Zip Code) <br />Name of Contractor(s): J "" ary-reVc `"- excAoaba1 Phone #: 5 (V77 y - l A Q 0 j <br />Contract Company Name: -3-W Gy�cne }- + F,)qrAkXA- -b YY) <br />Address of Contract Company: I LP 11 Yd Si- (!) Lj-;d 0. 1&j L40,5w <br />(Street Number- Street Name--City-Zip Code) <br />Current Use of Building: 51r)gLQ t'an')11L4 Hors -u <br />(Single Family -Multi -Family -Commercial -Government -Industrial -Vacant -etc.) <br />Type of Building Construction: &-.:i <br />(Wood Frame -Brick -Stone -Steel -Concrete -Other) <br />Proposed Work: ❑ In -Kind VLandscape ❑ New ❑ Replacement (not in-kind) Q Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: RP -r oje- coYY_ ynJe. Ent )P- -i' u61" <br />61on P"") -CSU <br />GZr2oe_ Cow) Coy-urr,4a i -b U%A �'IGc cQ tYw - <br />gr i � rv�an r- 5e r1�_ nq f a . ;cv 5 i rrro-c rel -e- <br />G� til l I lb -2 <br />Owner/Contractor Fag #: rJ-1'� " 5�PGi -rj� t�7' e-mail: J -W MZ9c.01\..1 UZtTE L' no l • cl1 <br />(Staff will co espond with only one designee) ONS W Li= y M A 12-r e- 5%9 !G�)vI A I L. � � <br />n� <br />(_� (,c..c,4.� ) and/or X <br />Signature f Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />