Laserfiche WebLink
i <br />Application <br />-FOR- <br />Certificate ofAppropriateness <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/SJCI iP/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE <br />\ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: kZ-� � l %W Application Number: NV I U — 18vu <br />Past Reviews: ® YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled <br />® Local Historic District (Name) <br />❑ National Register District (Name) <br />❑ NO <br />Title: <br />E04I 5 e <br />❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) �Q\ <br />Address of Property for proposed work: <br />(S�tjreet Number— Street Name—City—Zip Code) c� ct <br />Name of Property Owner(s): Phone #: l;)L 2- �p15S <br />Address of Property Owner(s): QH b lfz- , <br />(StreetNumber—Street Name—City--Zip Code) <br />Name of Contractor(s): vwvb�_— Phone #: <br />Contract Company Name: �F-t f' `�� <br />Address of Contract Company: <br />(Street Number— Street Name—City—Zip Code) <br />Current Use of Building:1� <br />fily <br />(Single amily—Multi-Fan—Commercial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: � '`,� JkV <br />flood 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: + ` P►"L `� �tc��1N5 CvU <br />\����'�M. LJ�1�,..dh`1.ia '�'C��r-��C�A'0.��\N - ���t1v.!��� �`�D���-�'\kti_ 1►.1�1�.�_CJ'11a� <br />Nl��nC <br />/� � � • ' V.i �� � `c��Vrz �� ��� �S�th-.> Ips �1^,i=�'f�l ��i tv a.� �i t n, Qu'1.�..s� `sve.��V�°� <br />Owner/Contractor Fax#:;�7q e-mail: <br />( or\spn it one signee)Xand/or X <br />Signature of \ �' Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />