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It <br />a JA <br />4SOUT88� Application �A WISSIpryfRso <br />- FOR - <br />\ <br />FACF. o sa <br />' - ''� Certificate ofAppropriateness <br />y <br />W �\ /j a p <br />HISTORIC PRESERVATION COMMISSION <br />x 1865 x 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: SBSJCflPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 61 l7' @0(% Application Number: 3017 — O&M) <br />_Past Reviews: YES (Date of Last Review) ��1 ��1 �q�S ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: (�LI e 19, 17101% ��i ULo-29 FP2 to hq- addeA to t (@Q aQej, <br />L) <br />Local Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To CommitteeEJApproved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />(Street Number !S'Ireet Name—City—Zip Code) <br />Name of Property Owner(s): ��CZ l� / Q,,rAk Phone #: 2 Z q1_7Z <br />Address of Property Owner(s): 6 G`�i+,., n r.� 14A sol( h_&A >j <br />`f mzJ'4k <br />eet amber— treet Name—City—Zip Code)Name of Contractors :R, // \ Phone #: Z���/ <br />() <br />Contract Company Name: ,7 <br />Address of Contract Company: 11q- <br />n(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: 4 &///1 41G /CA (/ <br />(dingle Family—Mzalii-Family—Commercial—Government Industrial—Vacant—etc) <br />Type of Building Construction: F'11�11t_4 D <br />(Wood Frame—Brick--Stone—Steel—Concrete—Other) <br />Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond vith only one designee) <br />khr- <br />and/or X <br />gnate- n �/ " Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />