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4 SOUTRB � Application <br />- FOR - <br />w \ Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />1865 of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http'//www.stjosephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574- 235 -9798 f. 574- 235 -9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY ENTRIES CONTAINED IN BOX «« «OFFICE USE ONLY <br />Date Received: 15' .4141A �Q 0 Application Number: " �-D /4_ — D� /S <br />Past Reviews: [R I YES (Date ojLaO Review) �D ,� �QTfn ❑ NO <br />Staff Approval authorized by: T . gyp <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />Local Historic District (Name) _ W' <br />❑ National Register District (Name) <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: 1 3<06 <br />(Street Number— Street Name — City —Zip Code) <br />Name of Property Owner(s): r r, Jry l Phone #: 6_7 ZS e�3 7z <br />Address of Property Owner(s): <br />Name of Contractor(s): /'I. ire �ocya t> <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number— Street Name — City —Zip Code) <br />Phone #: <br />(Street Number— Street Name — City —Zip Code) <br />Current Use of Building: 5.`n , lc ,C,.,.; <br />(Single Fan <br />Type of Building Construction: <br />(Wood Frame Brick — Stone — Steel— Concrete — Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape ® - New ❑ Replacement (not in -kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: e' 4 / - / Z /,,, p , /Z9 Ze,r' s y�rc <br />G1 � « 4 1 7 .1 t�n'f?7 ��r S �JGG� /SH dl� /7n�iiC in ��r / iFf"V'_ W.i�h ��,� 2Jnnil fJf +`vet.ii Fr•, +mot <br />Owner /Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X and/or X <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />