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Application <br />-FOR- <br />Certificate ofAppropriateness <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/SJCBP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st-jos6phJn.us <br />OFFICE USE OtNLYS»»>DO NOT COMPLETE ANY ENTRIES CONTAINED IN TFUS BOX«««OFFICE USE ONLY <br />Date Received: f11 1 i Application Number: of -1 .Y ) <br />(nteoiLat Reiw) <br />PastReviews: ES ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: �? <br />❑ Local Landmark Ef Local Historic District (Noose) fit 1� i a <br />❑ National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) " <br />Address of Property for proposed work: q117 Mf}}jJ 1 roti pI�� s©, MND 46b[(, lie <br />(Street Number—Streekame—Cit)—Zip"Codee)).�, <br />Name of Property Owner(s): c_t'►FP�L('�g/).i��� Phone #: <br />Address of Property Owner(s): 1+10 �%Wl-rOV PLP46 S©. PrND— "rt-av(b <br />(Street Nuihber—Street Namel City—Zip Code) <br />Name of Contractor(s): 67,) -90&� 1-DFR Phone #: S-4� 773--o546 <br />Contractor Company Name: -S LAP- ewm, \1 <br />Address of Contractor Company: (qs2 <br />(Street Numbers Street Name—City—Zip Code) <br />Current Use of Building: S/luG,t 4Mii_�l <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc) <br />Type of Building Construction: __ i)nOD M,5 <br />(Wood 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) <br />Description of Proposed Work: <br />26 SOS M C--" ON SOt?' �RM <br />t 4vc�t- nr7 -/fir rKc r- s [ . N() u ttM rx tcrctuu� <br />Owner/G. nt ete, : #: a -mail: jG(rlP✓r� ('G�� f"Q ��/`t�r �Omil <br />,s,, c%�tsi�^�dohC-f✓kgil;• info Gj5e5(nCjJqhCt. C0M <br />and/or X <br />Signature of Owner Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />