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Application <br />-FOR- <br />Certi ZCate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, iN 46601 <br />http://www.stjosephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLI'y»»>DO NOT COMPLETE ANY ENTRIES '1 ' ' ' I 1 If 1i j1 '. ' f .' <br />S CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 0 0117 Application Number: x017 —U=99 0509 <br />Past Reviews: ❑ YES (Date of Last Review) b 13013013 ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ® Local Historic District (Name) C04 tidadpe C1 eet <br />❑ National Landmark - ❑ National Register District (Name) <br />n <br />Certificate of Appropriateness: <br />❑ Denied <br />❑ Tabled <br />❑ Sent To Committee <br />❑ Approved and issued: <br />„,,.... ..,.,.„....... ... ,.„,,.,,1 11 „,.. , ......... . 1, „, , , . .. <br />(Please Print) l a� <br />Address of Property for proposed work: / 3-2 <br />(Street Number Siree e—City—Zip Code) (e�j <br />} <br />Name of Property Owner(s): W6 one <br />Address of Property Owner(s): /: W M - �/ S e .41! Oc (p lJ <br />umber— 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: 5e�,. , <br />(Singl 'gamily—Multi-Fam' ommercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <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: <br />J � � <br />Owner/Contractor Fax #: e-mail: 4/L[3 -,t GCS- �(� �dQ,C �•� <br />(Staffwill correspond with only one desi <br />X and/or X <br />Signaure of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />