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�SpvTIIB Application yG�NMISSIOryfgs <br />�Nlyi�i�t�t%'1d -FOR- <br />NEACF d Certificate ofAppropriateness m <br />. a HISTORIC PRESERVATION COMMISSION <br />■ 1865 R of SOUTH BEND & ST. JOSEPH COUNTY "'yt *yarn <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosepheountyindiana.com/departments/SJCB P/index.httn <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONL 111111111 <br />DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: _ tr lug � . @016 Application Number: N 16 — 0501 <br />Past Reviews: YES (Dare ofL.Revtew) a5�aa I ao�a NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date:-'" �'-" ►Vlllt� ��k�-r�i0lft <br />❑ Local Landmark ® Local Historic District (Name) C-0.91 wat�n�vef <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ DeniedElTabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) n / <br />Address of Property for proposed work: i rte! WV/1- <br />(Str et Number— Street Name—City—Zip Code) <br />Name of Property Owner(s): Y*K/ Phone #: <br />Address of Property Owner(s): -s ? <br />(Street Number— Street Name—City—Zip Code) <br />t 1 <br />Name of Contractor(s): 9� Phone #: s — -,Fe29 9 <br />Contract Company Name: —S-14.111,574 - 42 - WOO - ma/i„6 <br />I <br />UVA <br />Address of Contract Company: -1176 U,! <br />NnO Al sf2-- <br />k (Street umber—Street Name—City—Zip Code) <br />e <br />Current Use of Building: <br />(Single <br />Type of Building Construction: _L(,rA4, <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 />N <br />Description of Proposed Work: _�� t9� e'► <br />Owner/Contractor Fax #: � 3 ��J � Z e-mail: Lel%f o,o xed / 11,14'1/f �1,t9 o ,. ce PL,--.. <br />(Staff will correspond with only one designee) G7 <br />X and/or X <br />Signature of Owner Signature of ConlGictor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />