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Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAAI ED IN THIS BOX—OFFICE USE ONLY <br />Date Received: Application Number: (./7I— I — U" 0 CJ <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ NO <br />Title: <br />❑ Local Landmark ❑ Local Historic District (Name) <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: 9'14160-- C AR Qv I l <br />If (Street Number— Street Name—City—Zip Code) <br />—Name of Property Owner(s): ,f Y G.M C tS Co 6 a oj? A i -e Z_ <br />Phone #: Wi 16 2.2 <br />Address of Property Owner(s): %-SOL ( S 0 V 4ie flevv4 1W q b 4fl <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): LV A V I✓L Phone #: r 7q 7!0 971m. <br />Contract Company Name: <br />Address of Contract Company: <br />Current Use of Building: <br />Type of Building Construction: <br />(Street Number— Street Name—City—Zip Code) <br />M(jL+j ;vkr+(LY <br />(Single Famil}---Mzdti-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Proposed Work: ❑ In -Kind <br />(more than one box may be checked) <br />Description of Proposed Work: <br />Py itm P <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />❑ Landscape Yom, New a Replacement (not in-kind) <br />at,fi*ce �rakeN b3s�✓�o _ wtk� <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />b P cNiN 9 <br />X and/or X <br />Signa ure of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />■ <br />❑ Demolitions Re15 <br />5q X3�F5� <br />T <br />