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Application <br />-FOR- <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.stj osepheountyindiana.com/departments/Sf CHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ON <br />pp jj 7 n ONLY <br />D <br />Date Received: ,�71 a u Application Number: '3017 — ogaA <br />Past Reviews: ® ITS (Date of Last Review) 711, I ?017 ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: /� r <br />❑ Local Landmark � Local Historic District (Name) l fiopi n pok <br />ElNational Landmark National Register District (Name) it `t <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: e �� - v�� j-�J (Ni -l //' 6 �" C�/ <br />(Street Number— Street Name—City—Zip Cocke) <br />Name of Property Owner(s): Y i� .d Phone #: �.�� �% - `51,5 Is Z, <br />Address of Property Owner(s): �� �S^ <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s):Phone #: <br />Contract Company Name: f��-,/ J�J/��Gi�. '. /�?�j�✓�%�' <br />Address of Contract Company://�� /� y�,.?y! �� �?i�¢�/ C%4,-'�/, <br />(Street Number Street Name—City—Zip Code) <br />Current Use of Building: 1_11/ e& el <br />(Single Family—Mttlti-Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: �-In-Kind E]Landscape❑ New ElReplacement(not in-kind) ❑ Demolition <br />(more than one box ma)7be checked) <br />Description of Proposed Work: Gf <br />Owner/Contractor Fax #: e-mail: <br />(Staff will c es p . nd with onli; b esignee) <br />X and/or- <br />Sigi late Owmer­�, `'� yS5;n`ate of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />