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T <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USEii ONLY—>>>>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: g 1 101 -a0 l U Application Number: d 1l� — 09 13 <br />Past Reviews: YES (Date ofLas1R-1-) <br />StaffApproval authorized by: <br />Historic Preservation Commission Review Date: <br />I _ <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied <br />El <br />481 is /aolb I ❑ NO <br />Title: <br />Local Historic District pvame) l�q <br />® National Register District (7van,e) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) 1 �,;4(vlr4�et�u�.(�,,,er��:�,t.reetName—C(O—ZipCode) <br />Address of Property for proposed work: �it�, /.Ci L'�j��� <br />PO <br />dame of Property Owner(s): /(� ii,A `i� Phone #:Tc/6 --9Z C/ <br />Address of Property Owner(s): % �+�d2,� �i/� 1A1. IAK4� <br />"7� (StretNumber— Str etName-LCity—Zip Code) <br />Name of Contractor(s): le— C�19- Phone #: <br />Contract Company Name: <br />Address of Contract Company: -- <br />Current Use of Building: <br />Type of Building Construction: <br />(Street Number— Street Name--City—Zip Code) <br />Vacant—etc.) <br />(Wood Frame—Brick—Stone- Steel—Concrete-0ther) <br />Proposed Work: Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work:(:ll t'� `�-' / e�L-� lacrry%i Cfi f.- -- fee, <br />owner/Contractor Fax #: — <br />(Staff will correspond with on one designee) <br />X <br />Signa of Owne �� <br />e-mail: C✓✓brl'�- <br />and/or X - <br />Signa&rg,-Of Contractor <br />