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Application <br />-FOR- <br />Certificate 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 />" 1OFFICE USE ONLYy»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX<<< O 111 I'I 1 <br />jj�. «< FFICE USE ONLY <br />Date Received: & 1It�" 120 lb Application Number: @M — OCAOU H <br />Past Reviews: 0 YES (Date of Last Review) <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 />c�JLCPIYIbP1 Sd�0�� ❑ NO <br />Title: <br />® Local Historic District (Name) l hap ?nrk <br />National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />....,..,,, ... ,... <br />(Please Print) ���� <br />Address of Property for proposed work: 3,07 ,)A),� pa <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): j� A 1. �% i� it/�94�,£ri! C.�%~ Phone #: -3&IZ <br />i <br />Address of Property Owner(s): �0cs CJ7> ���.✓ �a � 1�/ ��� 13 <br />(Street Xumber— Street Name—City—Zip Code <br />Name of Contractor(s): �2 A� Phone #: %L) - 9,K 6 <br />Contract Company Name: ; 717,4c1 - ���1/ � �1�. ✓� Q <br />Address of Contract Company: <br />(Street Numb r— Street Name—City--Zip Code) <br />Current Use of Building: <br />(SingffFamily—Multi-FFa �ommercial—Government—Industrial—Vacant--etc) <br />Type of Building Construction: t<"90,09�j1,9.� taco (tn n a e, r <br />(Wood Frame Brick—Stone—Steel—ConWete—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: /as p � 2q_0 Ir ��t�n_v a,.,,i`�t✓S ; 7G� �: a1 �.•� <br />�,n ani <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X a--� r ,�,�� and/or X <br />Sigrfaiture of,6wner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />