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j U.11 a <br />-1 LLFbnco 6:&1 <br />Application <br />-FOR- <br />Certif irate 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/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.st-josqphJn.us <br />OFFICE USE ONLP>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX—OFFICE USE ONLY <br />Date Received: mail N R017 Application Number: x017 — 0534 <br />Past Reviews: © YES (Date ojLast Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />V NO <br />Title: <br />Local Landmark © Local Historic District (Name) i�II/P15rdP_ <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied Tabled Sent To Committee EJ <br />Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 10to'l 0C o Loh Q�P rind. --1 5 (0 Lo I (.P <br />(Street Number—Street Name—City--Zip Code) <br />Name of Property Owner(s): 44iOrryi- 1(V� 1-i(�1 Phone #: <br />Address of Property Owner(s): 10t,-1 \Vet 8(c�:< i`7 i d7U 0\\ k —I -I�� 4(,,(n( G, <br />f , - (Street Number --Street Name—City—Zip Code) <br />Name of Contractor(s):(�I� i �lof-1 1.q� 1 CI�OI,L2S Phone #: 6 7'-( r)�3-(oaOO <br />eA <br />Contractor Company Name: 1 a-DOr-N I� �i 1 fl(�f)11�5 <br />Address of Contractor Company: .1 .15 uc)aAeof1 'f-)i6ha_uo J Q �(o <br />(Street Number— Street Name—City--Zip Code) <br />Current Use of Building: 11P I <br />(Singl alt, <br />Type of Building Construction: t , 000X 'ti <br />(Wood 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) <br />Description of Proposed Work: ,A� (;+n Q ox\� i i '1 Y1Ni)? 4 <br />Owner/Contractor Fax #-' /7 cA59 -03�e mail: _-�roy�1,�2/J� <br />V <br />X and/or X <br />Signature of Owner Sign` a re of Cln ctor <br />APPLICATION REQUIREMENTS ARE LISTED ON VERSE SIDE— <br />