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A)� <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., qfi, %."A04661)1Tm 4661)1i <br />htip://wtivw.stjosephcountyindiana.com/departments/SICHP/index,htm <br />p:574-235-9798 f. 574-235-9578 c: SBSjCffPCQco.st-jaseph.in.us <br />OFFICE UYEO.NLI',>s,,>>,DONOT CONDI.L'TJ; ANX�NrRiF��D �1X<<<<<<OFFZCE USE ONLY <br />Date Received: PAP c2101-3 Application Number, 4-0113 A 6,, <br />Past Review:: YES (am Of Law Red-) NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />0 Denied <br />Title: <br />............. <br />Local Historic District <br />National Register District pv.,) <br />❑ Tabled ❑ Sent Te Comminte ❑ Approved and Issued: <br />(Please Print) <br />Address of Property for proposed work: X�(o E<),5f j Javc>,(K.e-) So`.v0-")C)1na-,--T,-n <br />(Street Number— Streef)Vame-0ty-72lp Co <br />S11 — Lf <br />Name of Property Owner(s): Phone N: I S1 <br />Address of Propertyof k ) <br />Owner(s): I L4 r) a (3 c -w <br />(Street Number—Street Name--City—Zip Code) <br />Name of Contractor(s): lv� \0 W) Phone #: Sn' M <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number --Street Name—Cify—Zip Code) <br />- Current Use of Building: <br />(Single F-amily--Multi-Family—Commercial—Ginernpo(ent—Industrial—Vac!ant---Cte.) <br />ti <br />Type of Building Construction: W Cl 1' U VYNI-� <br />(Wood Frame—Brick—Stone—Steel---Concrete—Other) <br />Proposed Work: OIn-Kind ❑ Landscape Z New AReplacement (not in-kind}_ ElDemolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />In tractor Tqx <br />will espa WI: h only ro;1,e Wi4nee) <br />X and/or X <br />Signatureo Owne Signature of Contractor <br />tICATION REQUIREMENTS ARE LISTED ON REVERSE SIDF,— <br />