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Application <br />-FOR- <br />Certificate of Appropriateness � m <br />o <br />HISTORIC PRESERVATION COMUSSION <br />I0 <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osepheountyindiana. com/departments/SJCB P/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 30 l <br />- Past Reviews: ® YES (Date of Last Review) <br />Staff Approval authorized by: <br />Application Number: -do I b — o L00 8 <br />300U - NA ❑ NO <br />Title: <br />Historic Preservation Commission Review Date: = <br />❑ Local Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledElSent To Committee ElApproved and issued: <br />..,.;..,..,.. ...,..... .,o.:. .� .,,,.... ..:�...,.. ....a. ........ ..A <br />(Please Print) /� / <br />Address of Property for proposed work: 7 /'fc 410 K ! (0 J �� <br />�� yy�� (Street Number— Street Name—City--Zip Code) <br />Name of Property Owner(s): lr�� %! IJ Y-�t� Phone #• s7`�' ✓�o� f! �2 <br />Address of Property Owner(s): A3 % Z-- (; 56 :z7 --,,j <br />(Street Number Street Name—City—Zip Code) <br />Name of Contractor(s): —T� G Bef— "e 2 Phone #: s7f/ ✓'.�o M's-il <br />Contract Company Name: <br />Address of Contract Company: lis -9 Z7- </j Tv <br />�/ (Street Number Street Name—City—Zip Code) <br />Current Use of Building: `% /%/d/ /-,, -- <br />(Single Family—Madti-Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: D Y-f�AEu <br />(Wood Frame—Brick--Stone-Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New [K Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />A 65' <br />5 <br />�M Ftp✓ y CcJr �n �s <br />_1&�D <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />X 14rr/a <br />Signature of Owner <br />e-mail: <br />and/or X <br />Signature of Contractor <br />