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-FOR - <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION °m i®' o`' <br />x 1865 x of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osepheountyindiana.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 CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: 1 ' 5 17 Application Number: 2-011 — ()q0,3 0 <br />a <br />Past Reviews: ❑ YES (Date ojLastReview) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />' ❑ Local LandmarkElLocal Historic District (Na»te) <br />❑ National LandmarkElNational Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledElSent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 201 W, ` AM A O T'0 4 <br />(Street Number—Street Name—City--Zip Code) <br />Name of PropertyOwner(s):-19DIANA LA1dMAR.KC) Phone#: (N) uD- 4.5N <br />Address of Property Owner(s): _.201 W. W o tJan . t-)quy ftw) 04(to I <br />(Street Number—Street Name—City—Zip Code) <br />Name of Contractor(s): <br />Contractor Company Name: <br />Phone #: <br />Address of Contractor Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: II cio. <br />(Single Famil),—Multi-Family—Commercial—Government Indztstrial—Vacant—etc.) <br />Type of Building Construction:)(] k Ii6e <br />(6Vood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed `Fork: ❑ In -Kind ® Landscape ® New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: See 0461C'Y M <br />Owner/Contractor Fax #: e-mail: r�= t26 <br />X . ` and/or X <br />Signature of Owner/ Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />