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AppfiCation <br />-FOR- <br />CeYti ICate 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.st osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY>»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />'Date Received: 9/11 ao 17 Application Number: 3017 — NO 113 <br />a017 ❑ NO <br />Title: <br />Past Reviews: © YES (Date ofLast Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Local Landmark <br />❑ National Landmark <br />❑ Local Historic District (name) <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledElSent To Committee F]Approved and issued: <br />i <br />(Please Print) n <br />Address of Property for proposed work:plDC �✓ !�! C%� t; f/'�f#�` 6m;t1�a ;14,5 -Yo <br />-� <br />(Street Number—Street Name—City=Zip Code) <br />-- <br />Name of Property Owner(s): i//7 -v i, A , Is'y S f42? Phone #: % v?76� ZO7, l <br />Address of Property Owner(s):/ti /f�L ter.�1�tt�fii�d �f L�'t, 141 K1117, <br />(Street Number—Street Name—City—Zip Code) <br />Name of Contractor(s): Phone #: <br />Contractor Company Name: <br />Address of Contractor Company: <br />(Street Number— Street Name—City—lip Code) <br />Current Use of Building:i��'Slt��Yi,/ s/AJ! tom' <br />(Single Family—Mttlti-Family—Commercial—Government Industrial—I'acant—etc.) <br />Type of Building Construction: R P—I C& <br />(Hood 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) Pi <br />Description of Proposed Work: 2 L f "�G' �iiC�� � � 1�xj G1wo-50'!v Ate/LZ 74�� <br />/�L7�i��<2S �i�,�Ly f'✓e/�Ti� �� �u2 /f��t� �`1 ,�/h�l��� /%�� S�2—�I?ii�lfc� <br />Owner/Contracto ax #: e-mail: <br />C <br />X � and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />