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Application <br />- FOR - <br />Certificate of Appropriateness m <br />HISTORIC PRESERVATION COMMISSION co <br />of SOUTH BEND & ST. JOSEPH COUNTY syr *tip <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj osephcountyindiana.com/departments/S JCB P/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />yl OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED�yIN THIS BOX«®««OFFICE USE ONLY <br />Date Received: 01 110 Application Number: (x\11 ( 0 <br />Past Reviews: YES (Date of Last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />dLocal Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National 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 />Name of Property Owner(s): <br />Address of Property Owner(s): <br />Name of Contractor(s): <br />Contract Company Name: <br />(Street Number— Street Name—City—Zip Code) <br />9—, ti%c- W_ 1:5,,4�cl Phone #: y/,I-- 70 V— �o�s <br />a- y <br />(Street Number— Street Name--City—Zip Code) <br />�F tl � / � • �GYC <br />Phone #: 5e? f _ <br />� Yq4 - //' <br />Address of Contract Company: 12-* W, 51- 5o.w <br />/' (Street Number— Street Name—City—Zip Code) <br />Current Use of Building: (16' <br />_"_=%/ <br />(Single Family—Multi-Family—Commercial—Government Indztstrial—Vacant—etc.) <br />// <br />Type of Building Construction: 0 ,,- k <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) 0 <br />Description of Proposed Work:i`at,�/l✓� <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond ith only o e designee) <br />X ` r `� �/L and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />