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i <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND d: ST. JOSEPH COUNTY <br />125 S. Lafayd#c Blvd., South Bend, W 4tS601 <br />httpJ/wwwAosephco=tyitxdian&mddepart[nmtWCHPrmdaltm <br />p: 574-235-9798 f: 574235-9578 e: SBSJCHPC@co.st josq*in.us <br />OMONSOON <br />PP=USE om AMV Vff RM QWAM V4 TjMjM4c"cA0MCEUSffOAu <br />Date Received: 05 .1 rAPPRedb u Nmnaber: <br />Past Revkwa: YES��rt " 1 f ❑ NO <br />Staff Approval authorized by: <br />71de: <br />Hirtork Preservation Cemmbdon Revbew Data � o . -1 •1 "/ ``� <br />❑ Loral Landmark Leval Historic District p*nd <br />Natbad Laadr10* N&dmdReghterDhtrfdMmd <br />CertitKaee of rlateaess: <br />Denied ❑ Tabled ❑ Sear To committee ❑ Approved and hsaea: <br />(Please Print) �p <br />Address of Property for proposed world: s�10 Sr,,.k SX &_ 54. <br />(Sorel Number- Street N duce, ity-Zip Code) <br />Name of Property Owner(s): _ Ki KE &x +ts- <br />Phone#: <br />Address of Property owner(s): 5 l o Soo i -t. S r - j arsen k 5+- - <br />rL&v;i Mmber-Streit Norm-Cltp--Zip Code) <br />Name of Coutraxtor(s): - tl n . C=yT v G an% ..� /Phone #: <br />Contract Company Name: <br />Address of Contract Conrpe ajn (,e c asy U.S. 31 44k"Illd . Z'A/ ANr3& <br />(Street Number`-StreetNcmu-Cdy-Bp Co&) <br />• Current Use of Bubidbng: <br />(Single FamDDily--Mrrlt�Family-C��rmertial--Go►vrnnurr�Inabcttrlol-Yacam-etc.) <br />Type ofBeliding Construction: Ae <br />(Wood FYa�me-Brie-+S7torre-,SteerComTete-Otikr) <br />Proposed Work: ❑ In-Kbnd ❑ Landscape ❑ New Q Replacement (rrot in -h4 ❑ Dermotitron <br />(more than one box may be checb <br />Description of Proposed Work: & - f;'nf dC6 AA&M, <br />OwntrlContractor Fax #: a -mail: i oy0 s at U►t� 60.5 . 5 a M1.3 IC45M <br />(Stewill correspond with only one designee) <br />X and/or X �. <br />Signature of Owner Sigasta ContracEr- <br />-APPLICATION REQUIREMENTS ARE USFED ON REVERSE SIDE-- <br />