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G <br />Application <br />-FOR- <br />Certificate of Appropriateness <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafayette Blvd., South Bend, IN 46601 <br />http://www.stj osephcountyindiana.com/departments/SJCHP/index.htm <br />p: 574-235-9798 f: 574-235-9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLYy»»> ' f 'I ENTRIES CONTAINED IN THIS BOX««< OF „ f <br />j DO NOT COMPLETE ANY < FICE USE ONLY <br />Date Received: CP Z / (7S 10 Application Number: 06 Vo— 1� =� I duo <br />Past Reviews: " YES (nate ojLast Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />101 Iq I aolb ❑ NO <br />Title: <br />Local Historic District (Name) }� 1 Jn-jad P. <br />❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) <br />Address of Property for proposed work: <br />Name of Property Owner(s):: t% 1A <br />Address of Property Owner(s): ty,t 2 - <br />Name <br />Name of Contractor(s): <br />Contract Company Name: <br />Address of Contract Company: <br />C1C1t 1� is �t1-f 5nm u <br />(Street Number— Street Name—City`Zip Code) <br />�-1C til K0lu 1 S Phone #: '-� qC s k7 <br />(Street Number— Street Name—City—Zip Code) <br />Phone #: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building: <br />(Single Family—Multi-Family—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: (1n'7 [A t ,N " --,'TSj,� <br />(Wood Frame Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: ❑ In -Kind ❑ Landscape �ew eplacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: t �'"� U.J S <br />Owner/Contractor Fax #: e-mail: -ivxA' (D iA e 4P o o\i w, iL — CcA <br />(Staff will torr pond with oft one27ee)Oand/or <br />X <br />e of Owner / Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />\j <br />IDE— <br />