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Application <br />-FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION ° lam' <br />" 865 of SOUTH BEND & ST. JOSEPH COUNTY Syr H vyaco <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http: / /www.stj osephcountyindiana .com/departments /SJCHP /index.htm <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX« OFFICE USE ONLY <br />-I <br />Date Received: 1 I / 17 Application Number: (X0 17 — 0331A <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied El Tabled <br />31 ❑ NO <br />Title: <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: C/`1 <br />(Street Number— Street Name — City —Zip Code) <br />A WfA C Name of Property Owner(s): Phone #: <br />Address of Property Owner(s): 9_,2o WftI f.& e,/ W L*�,/ <br />(Street Number— Street Name —City —Zip Code) <br />Name of Contractor(s): 4 _,1� rs'G� i` Phone #:(57 ; '-'5 '1?Z?_' <br />Contract Company Name: j �/� / l � y'IQ(04 <br />Address of Contract Company: <br />(Street Number— Street Name —City —Zip Code) <br />Current Use of Building: 1,V6� I- ,A'j j /(( � <br />(Single Family — itlti- Fami1�6— Commercial — Government— Industrial— Vacant —etc.) <br />' J <br />Type of Building Construction: W0,9f) + F_ <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) <br />Descript' n of Proposed Work: o i 2 4 , 07w e l G2c� �In � s o2l <br />1 1,10 � r � , / , V��9 % l�if3� �✓� n Yom/- ���/L� <br />ci/t i; i U ( � ��ll i.�' A) �I LLI2 AAA f�aWC- ! r &bQQ2 j 3J '7 7_ <br />Owner /Contractor Fax #: e-mail: S AA, cl (Q A-er- V /_' Y u CU" " l <br />(Staff will correspond with only one designee) <br />X and /or X <br />r <br />Signature of Owner Signat ure of C rac or <br />— APPLICATION REQUIREMENTS ARE LISTED ON I EVERSE SIDE— <br />