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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 osephcountyindiana.com/departments/S JCHP/index.htm <br />„ "p. 574-235-9798f. f. 574-235-9578 e. SBSJCHPC@co.st-j1oseph.in.us . 1u <br />OFFICE USE ONLY -»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: l / Application Number: 60\ — I — 01170,J <br />Past Reviews: IR YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />1 �itf RQ {7 ❑ NO <br />Title: <br />© Local Historic District (Name) l II0D41 O -1L <br />MNational Register District (Name) u % <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />g <br />(Please Print) <br />Address of Property for proposed work: S13 1014 k tL '4 V t �7` <br />0vp, <br />(Street Number— Street Name—City—Zip Code) <br />Q Q <br />Name of Property Owner(s): J Y� m_ -:s14 cc, � r Phone #: v <br />Address of Property Owner(s): o L 3 ►On -,,.k, [C' p (J e— S4 VA' r 3 Ct-J t3 e -J <br />(Street Number— Street Name—City--Zip Code) <br />Name of Contractor(s): Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building:/ -/1 /'-0r4 / /Y <br />(Single Family—Multi-Famil)—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: Woon <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ji� New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) , <br />�,,��✓�+ <br />Desclription of Proposed Work: Cfy�� �L r,i G� %a CEJ Ex D' Q J.lniv.> 12A'a i,o <br />GL ,I.%}.1�f7�Wn� <br />9 _,i�—� fl'v►n , ,%4v 1 16 i X9.2 -QS.' ltlfllrtQ <br />��• �!.D�%�.vey� ✓UCi -�?/1 �% /I �� J .v,... o L��� !1�/ea <br />Ownertontractor Fax #: <br />(Staff will correspond with only one designee) 1A— - �l.�r AA -e) A ,AaA).-e� <br />X SG �and/or X. v /) Ger,,ry, <br />Si re of Owner ' Signature of Contractor <br />t� <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />