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�a.M <br />ops°',gd A.p <br />-FOR- <br />its, �% Cern cute ofAppropfiateness. <br />HISTORIC PPIESSERYATION COIVIlVIIMON <br />�sss ofSOMM MM & ST. JOSEPH Coufff <br />125 S. i afayeft Blvd, South Bend, IN 46601 <br />. bttp:1/www4osephwmAymdima c arddgmim=WUCE[P mdex htm <br />p: 574-235-9798 B 374-235 9578 e: SBS7CHPCQa Co.St-joseph is us <br />u.���„���„r.,�,. �.���� n.�... ���.��y�....� �.���.����� u...��..i�. ni1emu. 11.1b,.11 <br />UFFICEi/ 0Mr-I»9i%b0 NOTC(RM=ANYENI=CONTAMUDIlYMSEO%E«<<<0]WLffMEONLY <br />_ Date Reeeived: �� �7 Appliimnai Nnmher. W17 — o b a a A <br />PastReviews: YES (cf�l $,� f ����! ("� NO <br />Staff Approval autiiorimil by: <br />- Historic Prescrvtffi= Commission Review Date:O (AVF P, I q 17,011 <br />��I�calLandmark LeedBIisWrkDistactjw.4 <br />Natioudlmdmark 0 Naft0vARegisEerDist ictPk.,j <br />CerE'dicate oiApgropriatenes� <br />Dented TATO SentTo Committee Q Approved and issued: <br />(P ease Print) , � <br />Address of for ro used work: 02 �I�''� <br />Property for P P s�!?,lc S• <br />(SrredKmnber—StreetNmne—City—Tap Code) <br />Name ofProperty Owner(s): Vj <br />l I Address ofProperty Owner(s): �% 6 <br />Name of Contractor(s): e t .tc <br />Contract Company Namee <br />Phone#: y -- 360- <br />PreetNumber—SYreetNmne—City—Tip Co*) <br />d4v,fPhone#: <br />Address of Contract Company; . aZ ND r s�r� �.L <br />preetNwnber--- Street N..:..e—Qtj—Zip Code) <br />CurrentIIseofMadbW �a /77 <br />(SingleFmraly�tfirlii-Family—Commercial=Govarnmer�t—Irahrstriab—Yacmr�etGJ . <br />Type oflBmlding Consttnction: <br />oYoodFnww Brick—SMe—SYeel—Con=k-- ther) <br />Proposed Work In Mud ❑ Landscape ❑ New ER Replacement (rot ink ❑ Demofftion <br />(more than one box may be checked) <br />Descripiioa�pf Proceed Work:ntaa q1 t-- <br />if .4AA <br />Owner/Contractor Fax #: a -matt:, 'd,-ZIYK. 4e!'` �-�S� Y4491- . CGtk <br />(SwffwiII cwraTond with only one designee) <br />X % r� and/or, X <br />Sipiat&e,40wner S�gnatnre of Cotttractor <br />ADDS Tr+A9`lf WW DMWkTiiD VrLMVr 9rQ ADL` T TQTCII ALIT DLR7ITDQL` C7ilV <br />