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Application <br />-FOR - <br />w �. mace � <br />a Certificate of Appropriateness <br />R m HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosepheountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLY " 11'DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«<• OFFICE USE ONLY ' i1 <br />Date Received: �� Sit- 0 Application Number: ® <br />Past Reviews: &YES (Date of Last Review)-'/ 1012— ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: s �� ) 2 b I - - <br />❑ Local Landmark En Local Historic District (Name) TC ,',,\ \ Or, <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledElSent To Committee F1Approved and issued: <br />(Please Print) X19 S, 5rt/,_( T& <br />Address of Property for proposed work: 1 / T <br />(Street Number—Street Name—City—Zip Code) <br />Name of Property Owner(s): STS, �6� 1 - t_CC—dh }l Phone #: �Z 0 �5 6 7? <br />Address of Property Owner(s): <br />(Street Number—Street Naine—City—Zip Code) <br />Name of Contractor(s): Tory 16';S� Phone #: 57,- 7 7 051-16 <br />x Zvi <br />Contractor Company Name: So lv FevA y s'Of'tS <br />Address of Contractor Company: �z �/� /" to Gid _ (I <br />5 . (V.z' ��Gt/0 _ �i%) 6S'�C) <br />(Street Number- Street Name—City—Zip Code) <br />Current Use of Building: v �, L2 _ <br />(Single Family Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: wooA -rj-aeV�e_ <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 />c (- <br />Description of Proposed Work: �ic V`� SOIGf 6iIiil5 /_j J <br />-hV, % Wt Av r, tt Le,,� <br />bP, r9n -hAA, fr-or,-F J110 4-,.o' Vic, J =r_a9fs,dc'< <he Ef&cam. <br />Owner/Contractor Fax #: <br />X <br />Signature of Owner <br />e-mail: -5m q eI.jr edtL) <br />and/or X <br />Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />