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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-josephJn.us <br />OFFICE USE ONLY! - > — >DO NOT COMPLETE ANY ENTRIES CONTA IN THIS BOX «« «OFFICE USE ONLY <br />Date Received: �.I.I� Application Number: LOI L — <br />Past Reviews: ❑ YES (Date oJLast Review) 0 NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Title: <br />Local Historic District (name) f 1 V C y zeyd <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) ��}} '' rr J /" • <br />Address of Property for proposed work: t7t 15 - 4a mmmd ' P f acs Soo v U � l , *10(oc) r <br />(Street Number— Street Name�ity --Zip Code) <br />Name of Property Owner(s): 1-(d,( (rha C YN Phone #: 574 ' lal 3 <br />Address of Property Owner(s): /N S h�re� rt Y t K1 a -�! ( w "s 1 7 <br />(Street Number— Street Name —:00 —Zip Code) <br />Name of Contractor(s): MU c (AMy OY1 <br />Contract Company Name: � <br />Address of Contract Company: <br />Phone #: n4.3 2.3 '105`7'71 <br />A , .' L (Street Number— Street Name — City --Zip Code) <br />Current Use of Building: I` ILL 1`[Jli/►/�t <br />(Single C'I Family —� M - ily— Commercial — Government — Industrial — Vacant —etc.) <br />W <br />Type of Building Construction: DI � Q.V)Il , <br />(Wood Frame — Brick -- Stone — Steel -- Concrete— Other) <br />Proposed Work: ❑✓ -Kind ❑ Landscape ❑ New E2 Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked)) .n r,� .`,� ,, ,� (► <br />/ D / � kescription of Proposed Work: eowt W I a � � .SY N ► Iof p 671 ru v , r'evkte, <br />I .A Ate_. A^ -(A.- A. .• J _ /A /Y1. 1i 4%— _ _ �.w .IA.A A OV. f IIA.r.. ...I I. -A..% <br />A_(M <br />Owner /Cont ractor Fax M 574' -;tI g4og e-mail: h @ <br />(Staff will or with only one designee) <br />and /or X <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />