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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 osepheountyindiana.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 Oft Y>»» <br />Date Received: 1D•1O • 1 <br />Past Reviews: ❑ YES tamp/wrxewcw/ <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 />USE ONLY <br />Application Number. )n 1 — t O, <br />❑ NO <br />Title: <br />\ <br />I\ - <br />® Local Historic District (Nm e) "' MPI V) PCr'"/ <br />l. <br />{� National Register District (Na 4 <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Prim) ('L,- v o y-QS4— <br />Address of Property for proposed work: O ) J U <br />r/�(Street Number— Street Name—City—Zip Code) <br />Name of Property Owner(s):^9 /Q 1 11�1i(1� I (1 Q , Phone #: lbQ <br />` <br />Address of Property Owner(s): D �Q 1 v <br />jeeett Number— Street <br />iName/—Cit)—Zip Code) c�—C7+L, 11n <br />Name of Contractor(s): [ 1 Q �i YhQ r1�1 Q� 1 Y 1(�� (� n ul — (7� Plfone #:Q • () I�p { �S (O <br />Contract Company Name: --V 11 U y� ( v I v��1 f� <br />Address of Contract Company: (O 3M "1 6 � ' ` —� � � SSD ` t S r 1 ry I l q c" o 3 <br />(Street Number— Street Name --City —zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commercial--Govemment—Industrial—Vacant—etc) <br />Type of Building Construction: Y-gMQ <br />(Wood Frame—Brick--Mone--&eel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checkea) <br />Description of Proposed Work: � :. C�:.._,.. +a <br />13 <br />—446-5 'r1k JSy / 11;x(, o �a� l.� 4P q= El - o I <br />�q �(�l <br />Owner/Contractor Fax #: dtY i `/ <br />+5--o "u, `] email: <br />(StaQ'wiy4orrespond with o t one designee) �- <br />X - .�i�i.,t-�a.P and/or X <br />Signa ire of n r Signature of Contractor <br />—APPLICATION UIREMENTS ARE LISTED ON REVERSE SIDE— <br />