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W
<br />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 osephcountyindiana.com/departments/SJCHP/index.htm
<br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us
<br />OFFICE USE ONLI'S»»>DO NOT COMP THIS ««OFFIC11 LETE ANY ENTRIES CONTAINED IN TS BOX« I f
<br />E USE ONLY
<br />I
<br />Date Received: 1 ,101 11
<br />Application Number: do I 1 — 011 4
<br />Past Reviews: © YES (Date oJLastReview)
<br />131051 30((1 ❑ NO
<br />Staff Approval authorized by:
<br />Title:
<br />Historic Preservation Commission Review Date:
<br />❑ Local Landmark
<br />Local Historic District (Name) �IV PIC; i (l e
<br />❑ National Landmark
<br />❑ National Register District (Name)
<br />L
<br />Certificate of Appropriateness:
<br />❑ Denied ❑ Tabled
<br />❑ Sent To Committee ❑ Approved and issued:
<br />„,,......,...,,,.........,,............,,....o,.....................,.,.,
<br />.,.,,.,..,.„„...,..,...,,,,,, , ,,,,,.,.,., ,,,,.......„.,,,...,,,.,,.......,,.,...,..,._,..,,..,.,,. ,,, ,.,.,....,,.,,■
<br />(Please Print) cc�
<br />Address of Property for proposed work: V I CaU (_ X311 �) - SL u 3M�
<br />(Street Number—Street Name—City- Zip Code)
<br />Name of Property Owner(s): ) µ LT t� CA Phone #: Ll q(:) S Co l 2 3
<br />Address of Property Owner(s): 9317 �I©1, 9J A l) _ �1; s T ai �fJ7 l t.� %i
<br />(Street Number— Street Name—City—Zip Code)
<br />Name of Contractor(s):
<br />Contract Company Name:
<br />Address of Contract Company:
<br />Phone #:
<br />(Street Number- Street Name—City—Zip Code)
<br />Current Use of Building: �l ks t'-, -�-i�► l L `I
<br />(Single Famil),,—Multi-Family—Commercial—Government—Industrial—Vacant—eta)
<br />Type of Building Construction:
<br />(Wood Frame—Brick—Stone—Steel—Concrete—Other)
<br />Proposed Work: ❑ In -Kind ❑ Landscape 0 New ❑ Replacement (not in-kind) ❑ Demolition
<br />(more than one box may be checked
<br />Description of Proposed Work: q �j t 0 V"3 "--
<br />Owner/Contractor
<br />Owner/Contractor Fax #: e-mail: 1�� Yom- � ��� Lti (1 co
<br />(Staff will c espond wit only o e design
<br />X f tfLry- _ and/or X
<br />Sign t of Owner Signature of Contractor
<br />—APPLI ATION REQUIREMENTS ARE LISTED ON REVERSE SIDE—
<br />
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