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Application <br />- FOR - o s� <br />" U <br />Certificate of Appropriateness � y <br />s � _ <br />HISTORIC PRESERVATION COMMISSION c o" ob <br />c <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www. stj os ephcountyindiana.com/departments/S JCHP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCHPC@co.st-josephJn.us <br />OFFICE �USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««O(F}FICE USE ONLY <br />Date Received: 1 /'3 Application Number: I'D — ©l D !T <br />Past Reviews: YES (Date of Last Review)❑ NO <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />Title: <br />k <br />❑ Local Landmark Local Historic District (Name) wN'L <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />„ „ „ „ <br />(Please Print)\'Z �{lp V, VC, • Stu -1 �s�...E N � (oL 1_i <br />Address of Property for proposed work: <br />(Street <br />jStNumber— Street Name—City--Zip'Code) <br />Name of Property .Owner(s):���R-tcl� +'SJ',' "v�Z.�o�S Phone.#: <br />Address of Property Owner(s): 1ZLllo r" • <br />(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): ��-� ^` ��.Sd *� Phone #: <br />Contract Company Name: I CO <br />Address of Contract Company: <br />e Street Number— Street Name—City--Zip Code) <br />Current Use of Building <br />(S gle Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction:r <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscap6 ❑ New A Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />77,7— <br />Description <br />Description of Proposed Work:�.vVJOc�Q <br />WbCa�'iC`&YLt��cv��t?+.x4` \.Til c•-,�. ALii �Ul.�rw.n 5'�.kt. L% WZC71AL <br />W`�ce�-� �fi�,k1\ e�(�S�sA-tG� �tv+.�� ��. ���..11�.�f�1Y..S� _ \ � MfC. N4',}±.1 �1.1t(+rQG4.+ts •lAi 1 �� �yQ�1'� <br />'CA _ QnJ0 , M <br />Owner/Contractor Fax #:S11, 714, _60(00 e-mail <br />(S i ' rrespond wit ly on esigne <br />X � and/or X <br />Signature of Owner Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />