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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/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 />Date Received: alio lG VI tYU 1 / <br />Application Number: wo 17 <br />— 9904 <br />Past Reviews:❑ YES (Date afLast Review) <br />® NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />® Local Historic District (Name) <br />t MJ <br />�WPJ IQ <br />❑ National Landmark <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) 1 V� Q M k Vi�,� V v\ m �) %)d I N %tQ, 01 <br />Address of Property for proposed work: <br />OV, <br />(Street Number <br />S�tyreet Name—Cih(�J—Zip Code) <br />Name of Property Owner(s): '�i �/1_��a i� V �i I �I !"1 f 1��1rYhonje #: <br />Address of Property Owner(s): 11 O UT & DP, %A dam/ r\ Ul , -t: N <br />q� <br />(Street Number—Street Name—City Zip Code) <br />Name of Contractor(s): k l(� p ,` 11� � �( `T C I�'(1 Phone #: L4 — 25q — 310 1 <br />Contractor Company Name: M M%r\e R h bk LLC <br />Address of Contractor Company: �Jvl� Imo' c{-��h�e� �1'�� �� �Il� ��'Q `7 1(l,5qS <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(SSiilln`glle((��Famililyl—�Mpulti- amily—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: ��p1.91A l V�& <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind dLandscape ❑ New ffReplacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) A �,� <br />Description of Proposed Work: ( 5ce U`ftlo � t11 esI mcl+e s) <br />Mri%ovAl 0t G\til\i%hV -P V\U OM intibahM\ny\ G� Of4 pepav", <br />�uc;ktcd 66_ - e aaA uwd -h=er &ue <br />Owner/Contractor Fax #: 151 L) 4�"l'� U`'1 e-mail: {>k QZ <br />X and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />