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Application <br />-FOR - <br />Certtficate of Appropriateness <br />Y `�.__�',� .� HISTORIC PRESERVATION COMMISSION <br />jes5 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http :l /www.stjosephcountyindiana. corn /depattments/SICHPiindex.htm <br />p: 574 - 235 -9798 f: 574 - 235 -9578 e: SBSJC1HPC@co.st-josej7hJn.us <br />OFFICEUSEb ,, NL __ P} `` » >> > ItONOr�d,�',,T ANYE S AINE TNTli IIOX « «s<?FFICEUS'EONLY <br />Date Received: / tcrr�r o/z Application Number: 1 -- 01?4)11!0 14 <br />Past Reviews: ❑ YES (ears ojtazrRr+de+rJ NO <br />Staff Approval authorized by: Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ❑ Local Historic District (tv i <br />❑ National Landmark ❑ National Register District (NaareJ <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />„ „..,,, ,. ... ... . <br />(Please Print) ( . 3 /1 1� A vc, <br />Address of Property for proposed work : / t <br />(Street Number— Street Name — City —Zip Code) <br />Name of Property Owner(s): I'M lit+ Phone #: ( 1 31 0 3 7 1 ` O z3 <br />Address of Property Owner(s): <br />r <br />(Street Number— Street Name— Ctty -21p Code) <br />Name ofContractor(s): f-"'� f Phone #: � 71 ) s yy� <br />Contract Company Name: Llo w e.4 <br />Address of Contract Company. A.: 0 I N '° .A� r--v S1 0 'fk &t), t, 7 bl <br />(Street Number-- fStreet Name -- City —Zip Code) <br />Current Use of Building: (� Fit /Ai <br />(Single Famil) fill Family— Commercial— Government Industrial— Yarant —etc.) <br />Type of Building Construction: W td F,% 4i t <br />{Wood Frame —Brick Stone--Steet— Concrete--0ther) <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: 14d wmeAq 11 f h f C ►ant 1Ji 4JVWf, V14 011 <br />,§ uA 5A ,4 4 sir / i,l ujet : fol r t,(� t t } any =,(r i4r <br />w. ' t t Yu t .t k P y { J t x” 4 o t t{k ct ir+�t �C jt f st i��✓ jf rf'C)� <br />Owner/Contractor Fax #: <br />(Staff will correspond with only one designee) <br />X <br />Signature of Owner <br />e -mail: mfleevli l P /y,Mr(i IA (tlAj <br />IJ y <br />and/or X <br />Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />