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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />1865 R 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: SBSJCHPC@co.st-josephJn.us <br />r.. OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: VYES <br />Past Reviews: <br />Staff Approval authorized by: <br />(Date of Last Review) <br />Historic Preservation C inmission Review Date: <br />Preservation <br />Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied <br />Application Number: 20) ( 0_ <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />1) \,� <br />❑ NO <br />Title: <br />❑ TabledElSent To Committee ElApproved and issued: <br />(Please Print) ` t p A 1 <br />Address of Property for proposed work:.- l I I A,' • C®k i', -i4 � 1 'IG� .�9. <4 UtD C <br />(Street Number—Street <br />�(Name—City—Zip Code) <br />Name of Property Owner(s): ��e� � t, )n,-lev'(C Ar)LZC) l tt J10j Phone #: <br />Address of Property Owner(s): (� 1� l (- f`��i✓` f'� �� <br />(Street Number—Str`�et Name—City—Zip Code) <br />a <br />Name of Contractor(s):` i `� �i; L> c �{ I,°j Phone #: 6_414 _0CLI BC1 G_;,, <br />Contractor Company Name: '— a <br />Address of Contractor Company:`�,t` <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: -k N \,A. 4 UK L�lrZt/L <br />(Single Fa�mily—Multi-Famil —Commercial -Government Inditstrial—Vacant—etc) <br />Type of Building Construction: S (h e_ ,( iC `_. LP-06CA <br />(Wood Frame—brick—Stone--Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New Pq <br />Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: 4_u C® o( -),,,f-'1 o <br />�`� , �7 c p T�..S C o &e,(—e- <br />o n n c (,\,-) fi -p tom, az-# 1 Gqf(cr— o f, 'rte �Gi <br />Owner/Contractor Fa : S-N<k-1' � l i e-mail: tii A -W � <br />X / �`� �� and/or X <br />Signature of vner Signature of Contractor <br />