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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION °o <br />of SOUTH BEND & ST. JOSEPH COUNTY <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-josephJn.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: �� I •�11 E�1Q��C Application Number: DA <br />Past Reviews: F1 YES (Date of Last Review) -! I �G' J ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ® Local Historic District (Name) Edg2oje� <br />❑ National LandmarkEJNational Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Number—Street Name—City—ZipCode) <br />Mme of Property Owner(s): 9PAI Phone #: '5;74 C) 29 f <br />Address of Property Owner(s): &S-5 /Ql y A211C2, A-ve <br />(Street Number—Street Name—City—Zip Code) <br />Name of Contractor(s): <br />Contractor Company Name: ✓��'� �w�//J <br />Address of Contractor Company: <br />(Street Number— Streets Name—City--Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Com mercial—Government Industrial—Vacant—etc.) <br />Type of Building Construction: 1pvc9c o <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: In -Kind ❑ Landscape MNew ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />1 <br />Description of Proposed Work: & x / ;1 <br />—vner/Contr to Fax #: <br />X <br />Sig at o wn <br />1 e r76W is fir , - (A/a'r-° <br />e-mail: @moi– -CZ�f <br />and/or X <br />Signature of Contractor <br />