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Application <br />-FOR- <br />w Cedificate of Appropriateness <br />a HISTORIC PRESERVATION COMIVIISSION <br />x 1865 R of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stjosephcountyindiana.com/departments/SJCB P/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: ,(/ C(li ,w is <br />A <br />Past Reviews: ❑ YES (Date ofLastReview) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied <br />Application Number: <br />❑ NO <br />Title: <br />❑ Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: tAA%1 P.0- S -k- a-1 <br />(Street Number StreetName—City--Zip Code) <br />Name of Property Owner(s): M # I nq�IS3 Phone #: Sl q •`��' �O - <br />Address of Property Owner(s): ` - _ fl t4a V,� 's T� t 0 &- ro e <br />(Street Number— Street Name-6ty—ip Code) , <br />Name of Contractor(s): �� Phone #: 7 `� • -Z <br />Contract Company Name: LmJ C's <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: 1 -lam LLQ i <br />(SingldFamily—Multi-Fami Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: 1-4- �� <br />ick—Sto,(—Steel—Concre{e—Other <br />(Wood Frame Br ) <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: O",tA�m 1 <br />-MM- r=ww i I <br />Owner/Contractor Fax #: a -mail: <br />(Staffw' orrespond with only one designee) <br />X and/or X <br />Signore of 0wner Signature of Contractor <br />