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Application <br />- FOR - <br />Certificate of Appropriateness o m <br />HISTORIC PRESERVATION COMMISSION <br />of SOUTH BEND & ST. JOSEPH COUNTY <br />125 S. Lafavette Blvd., South Bend, IN 46601 <br />http://%vn,iv.stjosephcount),indiana.com/depat tments/SJCB P/l*ndex.htm <br />p: 574-235-9798 P 574-235-9578 e: SBSJCBPC@co.st-joseph.in.us <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THiS BOX«««OFFICE USE OA'LY <br />Date Received: <br />Past Reviews: ❑ 1TS (Date aftarfReview) <br />StaffApproval authorized hy: <br />Historic Preservation Commission Review Date: <br />❑ Local Landmark <br />❑ National Landmark <br />Application Number: — <br />❑ Local Historic District (hare) <br />❑ National Register District(jva,,,e) <br />❑ NO <br />Title: <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and issued: <br />(Please Print) Z �� {�, �-1 -7N <br />I l <br />Address of Property for proposed work: 1 t t VL t oYY1 �f . :J O � N "1 kL' o f <br />C (Sh•eet.\rirnibe[—Siireet Nanie—City—Zip Cole) <br />Name of Property Owner(s): L,,5 ,11..Q_, ;D�„ -i<,,�,,.c� `,,L Plio►e #: 311 7 1 S -5 te� <br />� 1 <br />Address of PropertyOwner(s): i'l,0.. WeAN, 5�2 Zoo i " �%Ow <br />(Sh•eetMum ber treetAraine—City--Zip Code) <br />Name of Contractor(s): T K] 0 <br />Contractor Company Name: — �2 <br />Address of Contractor Company: <br />Phone #1: <br />(Street Arimiber=Street Ara»ie—City—Zip Code) <br />Current Use of Building: i t t V ��► ' 7 y,u i 1% <br />(Single Fanii!}=-1llulti-Fantll} Connuer�ial- CrorernnrenlArdtrsTrial—Ijtictntl—elc.) <br />Type of Building Construction: t i "r- iL <br />(iflood Fi anreSrick—StoizeSeel—Caricrele—Otliei) <br />Proposed Work: ❑ In -Kind ❑ Landscape 1� New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Thr" -k �-fo' <br />SI.C�M �•�- � ,�` )+ <br />trr� 1 , `L.�n hnn ,,��1�(un� � i4_. O NA KL+M <br />1.4 ,_ <br />i o n S 1 /17_ttan �r� t �r � i cI P M�vwm t� 0 <br />Owner/Contractor Fax#:e-mail: rQtalGVY-,DY-1 .o,.I�i..(-.0 <br />X and/or X <br />Sign- i -e of 014 er Signature of Contractor <br />APPLICATION REQUIREMENTS ARE LTSTED ON REVERSE SIDE— <br />