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Application <br />- FOR - <br />Cer•tificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND S ST. JOSEPH COUNTY <br />125 S. Laf vette Bled., South Bend, IN 46601 <br />littp://%�1N,N%�.stjoseplicountN,indiatia.cont/clepartments/SJCI IP/index.htnl <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCIIPC «co.st joseph.in.us <br />OFFICE USE JO:VLY>>> >DO NOT COMPLETE ANY ENTRIES CONTAINED IV IMS ll0\«««OFFICE USE ONLY <br />Date Received: < l / 1 j 2►0 ) -7 Application Number: <br />L <br />i <br />Past Reviews: ❑ YES (Dare of LauRr iea) ❑ NO <br />Staff Approval authorized b}: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Title: <br />ffLocal llistoric District (Aa,ue) l~ w_Le je_J_U_ <br />❑ National Register District (\"ante) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) Q�j �l n co In uu.)Gt GCtC*-V <br />Address of Proper" for proposed cork: <br />(Street Nunrbereet Nanie—Cit}—Zip Code) <br />Name of Property Owner(s): I"1 (m'ti( na Lmc' Phone #: 532-576-07q <br />Address of Property Owner(s): �J' b �J Si- T05flok —,;+ c_---Ot)fk Ter0l IN `t `1 r 60[ <br />(Street MunbIr—Street A'anie—Citi•—Zip Code) <br />Name of Contractor(s): <br />Contractor Company Name: <br />Address of Contractor Company: <br />Phone #: <br />f (.Street Ntunber— Street Nafire—Cit, —Zip Code) <br />V <br />Current Use of Building: o cav)f <br />(Single Fanril►—Alulti-Faniih—Connnet cinl—Gorernnreirt—/nrlustricr!—Vacurit—etc.) <br />a <br />Type of Building Construction: r1 G� <br />(Wood frame—Brick—Stotre—Steel—CaJic-i-ete—011ici) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New <br />0n7ore than one box nim- be checked) <br />replacement (not in-kind) ❑ Demolition <br />/ V 1�j <br />` <br />`� C� ©�S, <br />Description of Proposed NYork: tCPC� i� (,ca1rlG�Qe US <br />% <br />t eXaC_ `�J <br />SC�Y11L_►�� <br />01A I>jI\dok�'ot p -n <br />ayi <br />reallu <br />detevtbralec . <br />'-T ,A -erg -- k e h rt c.L 5 A-ui4- <br />� w h <br />+n-) <br />(a M P I, ['o i tk <br />r O Cit' P V-\ f u( C e Vh -e vd— <br />Owner/Contractor Fax th e-mail: <br />AMX and/or 1 <br />Signature of Owner Signature of Contractor <br />