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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/SJCB P/index.htm <br />p: 574-235-9798 f. 574-235-9578 e: SBSJCBPC@co.st-josephJn.us <br />OFFICE USE ONLY% >> >DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received: OR 6 I M7 Application Number: �O 17 — 06@G <br />Past Reviews: ® YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Preservation Commission Review Date: <br />7fac�iao�V ❑ NO <br />Title: <br />❑ <br />Local Landmark <br />© <br />Local Historic District (Name) I�IPl6i t? ill(i�/p <br />❑ <br />National Landmark <br />❑ <br />National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ TabledEJSent To Committee ❑ Approved and issued: <br />(Please Print) f n, - � j q b I <br />Address of Property for proposed work: 1 l 71 Q `( A"vusldeY_ e YIUI "1 <br />%� ,.` (Street Number— Street Name—City—Zip Code) '7 ( /� `� <br />Name of Property Owner(s): A n c1 q -- Z�CJ (jam . VCL QA( Phone #: � [ bl �LI "/ –� 41cD <br />Address of Property Owner(s): lC) La 9 1\4 P,cs <br />1(Street Number— Street Name—City—Zip Code) <br />Name of Contractor(s): (� 1C ��ls <br />e_ Phone #: ,21? <br />Contract Company Name: <br />Address of Contract Company: <br />(Street Number—Street Name—City—Zip. Code) <br />Current Use of Building: 1 \ Cl Im t l L% <br />(Sing1AB'amily—Multi-Family—CommePcial—Government—Industrial—Vacant—etc.) <br />Type of Building Construction: <br />(Wood Frame—Brick—Stone—Steel—Concrete—Other) <br />Proposed Work: In -Kind ❑ Landscape Lp New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may a checked) <br />Description of Proposed Work: 4f f) J 0 X 1 5 e9D–( A-- <br />�-�`� (n, V') -4 <br />AANQ.` bca c_ 4 y CA - to , 1-'t o J �. P ,h1�� k--` ` c� _ Ned— <br />on S' -`- r,>( . C � rc��� e — - rvtc�-CA\ e K 1 �A <br />1 <br />Owner/Contractor Fax #: e-mail: <br />(Staff will correspond with only one designee) <br />X <br />(Staff_ <br />� and/or X <br />Signature of Owner 1 (/ Signature of Contractor <br />—APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE— <br />