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Application <br />K, -FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION m <br />y 1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd.. South Bend, IN 46601 <br />http://%%-%vN%•.stjosephcotintyindiann.coni,ldepartnients/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC acost joseph.in.us <br />* I' <br />�fOFFICE » <br />(ISEO.VLI' »>DO \OT C'O,LE <br />IPTE ANV FN`rRIF.S CONTAI\ED IN TIIIS BOX«««OFFICE USE ONLY <br />Date R ` { <br />eceived: � (-q:>A' 11 ApplicationNumber: 2(_3M — \ Q) 32. V�6 C_ <br />Past Reviews: ❑ YES (nateoftastRe�h) ❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />(Please Print) <br />Address of Property for proposed work: <br />Name of Property Owner(s): <br />Address of Property Owners) <br />Title: <br />❑ Local historic District (.Vame) <br />❑ National Register District (.Fame) <br />❑ Sent To Committee ❑ Approved and issued: <br />t 1'unrber—Street \'ame—Cin=ZlpCocfe) <br />akt�� <br />Phone#: <br />9/I 1<�W Ate. �� � ��6I(0 <br />(Street Number—Sireel : 'nine—Cit)—Zip Code) <br />Name of Contractor(s): <�Iar J5n2r4y SVS16iS) Phone #: S741 '77.1 D$-y(o <br />Contractor Company Name: �A ll�/ 4eo4 d if 5� � l � <br />Address of Contractor Company: r <br />lgs2 la- ��4k + SSS <br />(Street Number— Street Xanre—Cit)--Zip Code) <br />Current Use of Building: <br />(Single nil)—.11uld-Fan y-Connnercial—Gorernmenl—IndnLvlrial-1'acant—etc.) <br />Type of Building Construction: 1Nc73� r4� <br />(d f ood Frame—Brick—Slone—Steel—Coitcrele—Other) <br />Proposed 'Work: din -Kind ❑ Landscape ONew ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />/� �L,. l ll 1 <br />Description of Proposed Rork: /YPOQSG -1-o }'mom, � r� a(� AvAedt skl 6. <br />roWonr eKd Qd S, /w- rend -r -ft f"oo�' Fer- a -i'at ti.�,i' IWfo <br />,./> <br />Owner/Contractor Fax #: e-mail: ACC:YLGA GI'V-070, 6M <br />X and/or X <br />Signa+oO%vneqr Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />