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Application <br />- FOR - <br />Ceti icate of Appropriateness m <br />o <br />HISTORIC PRESERVATION COMMISSION o co <br />of SOUTH BEND & ST. JOSEPH COUNTY syr r1a <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-josephAn.us <br />OFFICE USE ONLY»»»DO NOT CONn'LETE ANY ENTRIES CONTAINED IN THIS BOX««< <br /><OFFICE USE ONLY <br />Date Received: 'DJ, 117 Application Number: o i7 — 95a1t <br />Past Reviews: ® YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />® Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />II lab/Ile <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />ElTabled❑ Tabled F1Sent To Committee <br />❑ NO <br />Title: <br />❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: `i • Cr'1Sol 41.-, 12,,A _T/V C4 <br />(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s):,,"�-kWe, _t� f `A,V)0 r IC' (!1 C Phone #: s r- <br />Address of Property Owner(s): ( ,� , C P ,X �e � � �)u L4 (a (9 1 6 <br />(Street Number— Street Name—City--Zip Code) <br />Name of Contractor(s): a h("n R4 Q �( �(' Phone #: <br />Contract Company Name: ()t )C' ('1 C/1 p ()rA� j L <br />Address of Contract Company: Q e 1," <br />n (Street Number— Street Name—City--Zip Code) <br />Current Use of Building: ��� n cc 0 <br />(Single Family—Multi-Family—Comm$ ercial—C-o-vernment Indztstrial—Vacant—etc) <br />Type of Building Construction: Aofe, R((r k �. s4u cco <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New gReplacement (not in-kind ❑ Demolition <br />(more than one box may be checked) <br />Description of P posed Work: J) � fAaC _ _ 5:1—a -,tEle f- t -u r �k C-0 "'II IZc�i <br />7 ' t: <br />t^ LT- rcl- t �(3�'''n�� ,� - ' cf t�'I n rfl�!� iii t,I1 C�ns�S_� <br />tsv4 c,�ia, /� inn�',tsc � _ i1n�1� -CZrVV pn <br />Owner/Contractor Fax e-mail:1���n',I�,�r <br />(Staff will correspo wone designee) <br />X an&gr X <br />Sienature.oi Owt4r, Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />