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Application <br />- FOR- <br />Certif icate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION c' <br />rats a of SOUTH SEND & ST. JOSEPH COUNTY 'yi ►��� <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stjosepheountyi ndiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCHPC@co.st-joseph.in.us <br />�..,.,.,.., ,. ....... .......... ....... ; , I..,.....,..,... , . ...„-..-,_....._ ,,.,,. <br />OFFICEUSE NLY»»»DO NOT COMPUTE ANY ENTRIES CONTAINED IN TIIIS BOX«««OFgFICE USE ONLY <br />Date Received: O 'n�"a201S Application Number: arils — `� <br />Past Reviews: ErYES (nate gLast Near..) ❑ NO <br />Staff Approval authorized by: j% Title: <br />Historic Preservation Commission Review Date: 02sl/_c. <br />1 n 2� t0 %s <br />B11"Loeal Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ED-NationaI Register District (Na ne) �c.X��1 /��'r ✓ <br />Certificate of Appropriateness: <br />❑ DeniedF1Tabled ❑ Seat To Committee ❑ Approved and issued: <br />(Please Print) 7Mb mlehl&ita j <br />Address of Property for proposed work: !V0 -go vmcju ju IsT 1jaJ it �t <br />(Street Number-41reet Name-C1ty-Zip Code) <br />Name of Property Owner(s): ' .G /a- +&jL4P <br />Address of Property Owner(s): � J;fr) <br />Phone #: <br />(Street Number, - Street Name -City --Zip Code) <br /><a-4su)444r <br />Name of GentrarWr(s): _G1 t .. Cgocw sy Phone #: 57y Z_2x7_-, %55e <br />Contract Company Name: - 1O+s o -S sa141 <br />Address of Contract Company: 41Z !j_ Zft0A%Gnr_ 18LOO. bad -INS -Vo .1&4 y(,(.o 1 <br />C.l (Street Number- Street Name -City -Zip Code) <br />Current Use of Building: 174ttL_ j^ <br />(Single Family-Ahilti- ily--Commercial-Government-Industrial-I,'acant-etc.) <br />Type of Building Construction: 1'v�J4.. <br />(1f'ood 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) p <br />Description of Proposed Work: ,�_�_ _-Z AMAC (i�*'.0j',) :je-t,�y��ii.f f <br />Owner/Contractor Fax #: e-mail: <br />(Staff tivill correspond with only one designee) <br />X and/or <br />Signature of Owner �g tore f Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />