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Y Y <br />- FOR - <br />Certificate ofAppropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafay ette Blvd., South Bend, IN 46601 <br />http: / /www.stjosephcounLy u iana .com/departments /SJCHP /index.htm <br />p: 574 -235 -9798 f. 574 -235 -9578 e: SBSJCHPC(a�co.st- Joseph in.us <br />OFFICE USE ONLP> » » >ll0 NOT COMPLETE ANY ENTRIES CONTAINED IN THIS B0X « « «0FF7CE USE ONLY <br />Date Received: 114 � o20 /eZ <br />Application Number: oW/dk <br />Past Reviews: [E YES (Date oftstR -.w) <br />❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark ❑ Local Historic District pQm,) <br />❑ National Landmark ❑ National Register District pvame) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued: <br />(Please Print) <br />W <br />Address of Property for proposed work: _?J5 6) re6 <br />(Street. Number —C n)� —Zip Code) (p <br />Name of Property Owner(s): J hp 01 4 /firm` � Phone #: <br />Address of Property Owner(s): <br />(Street Numffer Street <br />R <br />Name of Contractor(s): r Phone N: 9 74 — Wfip <br />Contract Company Name: 1A & ,F I <br />Address of Contract Company: 6 a L m <br />( Street , Number— Skeet,Vame --City —Zip Code) <br />Current Use of Building: l <br />P le- 40cf <br />tJ Stngle Family -Ylulti Family — Commercial— Gavermnent— Industrial Vacant —etc.) <br />Type of Building Construction: M e. <br />(Wood Frame Brick Steel Concrete — tither) <br />Proposed Work: ® In -Kind ❑ Landscape ❑ New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) <br />e1re� <br />Description of Proposed Work: dew r 111aSonry a] , - Pg/N h i n j U rfcl!ch7 n . <br />'Bricks w l/ be rp-Moved <br />Owner /Contractor Fax #: e-mail: <br />(Stnf" arrespond with only one designee) <br />and/or X <br />re ner r Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />