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Application <br />FOR <br />Certif <br />ICate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />httpglwww.stjosephcountyindiana.com/departments/SJCBP/index.htin <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE OASY»>>>>D0 NOT COMPLETE ANY ENTRIES CONTAINED IN TMS ROX<<<<<<OFF10E USE ONLY <br />Date Received:— &RmbE q Application Number. <br />Past Reviews: 0. YES (Date efLast R-1-) jof 11' 14 ❑NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />ElLocal Landmark Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Title: <br />Ed <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled El Sent To Committee ❑ Approved and Issued: <br />,....•....••„•_••.......... ...... . . . ......... . ... .... <br />(Please Print) <br />Address of Property for proposed work: 5/--7 IZ'vw A -V -e--, <br />(Street Number -Sheet Name -Cit <br />y, -Zip Code) <br />Name of ProperOwner(s): Phone #:5 7LI. L10. 6tj <br />ty q <br />Address of Property Owner(s): g -4 -'vol- Ave, <br />(Street Number- Street llfanieCity-Z' ".:Coils) <br />RAC - <br />q <br />Name of Contractor(s): <br />Contract Company Name: �k- s (' k Q -t 1� - <br />aJ :69 <br />Address of Contract Company: qD , (A4- <br />tr4ke-=StieetNami-Citli::-Ziii-.C(i4e) <br />Current Use of Building: <br />Q <br />(Singlei- iov-Com., l - <br />t <br />Fanfty-Mpffl�Fqm rciaGovcrtinzent-4ndustriaf--Vacant-etc.) <br />. , , <br />Type of Building Construction: W <br />-(Wi6dFrame-Brick-Ston"i��l-Conc'rete�Oihei) <br />Proposed Work: ElIn-Kind 1:1 Landscape -[D�Nevv 0 Replacement (not in-kind) [EDemolition <br />(more than one box may be checked) <br />Description of Pr6ipdicd Work: T44, r <br />0, Milt <br />t&' <br />27� <br />.o <br />s4q� ounp- , "a” 'W PD <br />Ktt n -tie .g <br />is" wag pati Yk bve A& <br />Own.er/Contractor Fax #: e-mail: <br />edr - 6nd " 1i <br />.1SA W'11.1 only one designee) <br />X and/or X <br />Signature of Owi cr Signature of Contractor <br />-APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />