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Application <br />-FOR - <br />Certi Kate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN AAAn I <br />http:/ /www.stj osephcountyindiana .com/departments/SJCHPf ndex.litm <br />p: 574- 235 -9798 f: 574- 235 -9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY F,NTRIFS CONTAINED IN THIS ROX «« «OFFICE USE ONLY <br />Date Received: _L� oZO /� Application Number: 070/0 — Q <br />Past Reviews: ❑ YES (Dore (Review) ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ® Local Historic District (Nome) _ <br />❑ National Landmark ❑ National Register District (Nome) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) p ` TAI Address of Property for proposed work: 1,10 1 � K &f- �Jduf , RN A I 1v <br />(Street Number— Street Name --city—Zip Code) <br />Name of Property Owner(s): p Phone #: !� 7 ' 1 - 3 y d 9�/p� <br />Address of Property Owner(s): 5 0 k f <br />(Street Number— Street Name — City—Zip Code) <br />Name ofContractor(s): PNACA� Tev.�tip, Ree t erul A t Kj <br />-64f #' <br />\ hone #: G7C.1- a3) -Xm <br />Contract Company Name: se, w.� l <br />Address of Contract Company: o Zl 1 1 . ,WOM k%kd . /Va C& <br />(Street Number— Street Name Code) <br />Current Use of Building: 5 11,E t � �, RA ta, �' f'-1 R -S Y PA tA. W, <br />(Singlt?Family Multi - Family— Commercial— Government — Industrial— Vacant —etc.) <br />Type of Building Construction: (.0nOd I t u... L <br />(Wood Frame— Brick -- Stone — Steel— Concrete— Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) E Demolition <br />(more than one box may be checkeaq <br />Description of Proposed Work: `' Q <br />(YV 0UQ. j b � k {@ <br />I bc,ut yard. Sh t,t!N, (3r.. Fat-tkb f hAt 6.4 � �t`j� t4 u dS <br />tx) fIW,nimI ! . -.% <br />Owner /Contractor Fax #: t(- a D- �7 C'7 e-mail: <br />(S i ' 1 correspond ivith only one design / e) <br />(. I SC?1 and/or X <br />Signat re of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE <br />