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SOOT►Ia Application <br />FOR - <br />r� <br />'AVE Certificate of Appropriateness <br />jj � <br />HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST, JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http:// www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPCCco.st joseph.in.us <br />OFFICE USE aVL15»»>DO NOT COMPLETE ANI' ENTRIES CONTAINED IN THIS BOX«««OFF[CE_,USE ONLI' <br />Date Received: i' 12/1-7 Application Number: — % 13 <br />Past Reviews: 2 YES (nateojtastReview) U 1?r ❑ NO <br />Staff Approval authorized by: Title: <br />s historic Preservation Commission Review Date: <br />Local Landmark❑ Local Historic District (,vame) <br />❑ National Landmark ❑ National Register District(,vame) <br />Certificate of Appropriateness: <br />EJEl <br />❑ Tabled ElSent To Committee EJ Approved and issued: <br />(Please Print) `` ,�7 r _ , l I,� <br />Address of Property for proposed work: 6, (y l �� ���Etl L /v %f 4% r �"I 5il. %)V -Ito 524 <br />(Street Number—Street Name—City—Zip Cocle) 1 <br />Name of Property Owner(s): F-Z41JP1J LGL 7i l re— it t,4'1 ELW—j Phone #: i 7 -1 <br />Address of Property Ow•ner(s):int% kJ2 <br />(Street Number -Street Name-Citj -Zip Code) <br />Name of Contractor(s): <br />Contractor Company Name: — <br />Address of Contractor Company: - <br />Phone #: <br />(Street Number- Street Name -City -Zip Code) <br />Current Use of Building: 51%Jc7C C 1rolq/L..Y <br />(Single Famili—Aftilti-Family--Conrmercicit—Government—Ltclustria!—l'(rcant--etc.) <br />Type of Building Construction: W Oz -"O <br />Wood France—Brick—,Stone—Steel--Concrete—Other) <br />Proposed Work: ❑ In-KindZ1 Landscape F] New Replacement (not in-kind) ❑ Demolition <br />(more than one box mm, be checked) i� /� <br />Description of Proposed Work: AN sA FC T V <br />Owner/Contractor Fax If: 57 71— e-mail: (Cl !Gf ­- C-? ✓tc� -7 �DV1t l c, V—, GU )N <br />? (� G S'5 Fi — <?e - <br />X and/or X <br />Signature of Owner Signature of Contractor <br />-APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE- <br />