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Application <br />FOR- <br />Certificate <br />OR- <br />Certi icate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjo§ephcountyindiana.com/departments/SJCB P/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: 1 13 117 Application Number: W7 — 0103A <br />y Past Reviews: ❑ YES (Date ofLast Review) <br />NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) 0 fln j A pab <br />❑ National Landmark National Register District (Nan,e) 't ' <br />'a <br />i <br />Certificate of Appropriateness: <br />ElDenied ❑Tabled ❑Sent To Committee ❑Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: A I 5OL t1 , Rr_--No )/V A" <br />(Street Number— Street Name—City-Zip Code) ( 57q) q0q - 30 (a achej <br />Mme of Property Owner(s): lf)'� G AVO OA,—N:4rY ,Jlel,( Phone #: 71, 9 d , - 3Z-5 5 <br />Address of Property Owner(s): C6 Z S A S 14L✓rN17 AVC 50i/ T h fgewo 1 /V Qd <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): kr) ! 5Ge? 510 Wr, ffwn CONS 1 t2(/G?l cel/ Phone #: <br />Contract Company Name: 1-i &jtl r reg S t l7( Ato A -AID 6?A1Si (,e.Uc; -i7U4/ <br />Address of Contract Company: <br />(Street Number= Street Name—City—Zip Code) <br />Current Use of Building: I /✓ 6 L.L= FA M (L Y <br />(Single Family—Multi-Family—Commercial--Government—Industrial—Vacant—etc.) <br />Type of Building Construction: v1/ 1/00ow 5 <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 />/I � <br />Description of Proposed Work: PU`T-Ct V 1 !1/ Nn_ D `/ i�JQe / 5 %1�iLikC 71 ilNl� <br />V��nifXMlS - l�)ir� nui ir► ar ('�{faQn. 12 - will (ngLl�d�` t in frame <br />er/Contractor Fax #: e-mail: <br />taff will correspond with only one designee) <br />t _ 6 and/or X <br />nature of Owner Signature of Contractor <br />