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Application <br />-FOR- <br />Certificate ofAppropriateness <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: SBSJCIIPC@co.st-joseph.in.us <br />OFFICE USE ONLY-- ­DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: %OLLI 2-'3• Zel —7 <br />Past Reviews: ' YES (Date ojLast Review) <br />Staff Approval authorized by: <br />Application'Number: c� 11 — (=)S 23 <br />131 3017 ❑ NO <br />Title: <br />Historic Preservation Commission Review Date: 13ln.-rl�2 <br />❑ Local Landmark Local Historic District (Name) Y2,lUe v -5)(A(,- <br />National Landmark ❑ National Register District (Name) <br />El <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />... _ ..,,...... .... ........ ....... .,..,.., ,.......,,,,�._ ...,.... „,� <br />(Please Print) <br />Address of Property for proposed work: t� CSTOL -D �C U SOUT L IS�C1S'� ( � <br />(Street Number— Street Name—City—Zip Code) LUOLO �0 <br />Fame of Property Owner(s): t ��T� C-1 A S U( Z? \ S Phone #: S --t:> G tZ3 8 <br />Address of Property Owner(s): 813 NoldpA Appip, SOuth Bolid <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): Owl)ev Phone #: <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name—Cit)--Zip Code) <br />Current Use of Building: Sin_ le �amil <br />Aingle Fami¢y—Multi-Family—Commercial—Government—Industrial-1 <br />Type of Building Construction: WOOd CffQtAP. <br />(YVood 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) tt _Q <br />Description of Proposed Work: min _o , iA. V)A 66e(dain'iill ffoA.om <br />blook, add <br />lands;r!anr�lr� rilnnfg. Qnd nlnn�o��le/�vt3 doa�.ar, �C'n/ r . 1. <br />owner/Contractor Fax e-mail: <br />eta, ff will 96,lrrespond with ly one des' ee <br />X ,Q and/or X <br />Si ure of Owner Signature of Contractor <br />—APPLICATI N REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />