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So�Tf11:� APPLICATION `AMM SS,UNfgf <br />FOR <br />�"�\,�,M,� a o H <br />CERTIFICATE OF APPROPRIATENESS a <br />yN <br />1865 <br />Historic Preservation Commission of South Bend & St. Joseph County <br />227 West Jefferson Blvd - RM 1123 — South Bend IN 46601 <br />Phone: 219-235-9798 Fax: 219-235-9578 e-mail: historic@michiana.org <br />A Certified Local Government <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USE ONLY <br />Date Received <br />Past Cases: YES ❑ <br />(date of last case) <br />Zoning Type: <br />Signature of Administrative Person if Approved by Staff. <br />Historic Commission Review Date: <br />❑ Approved <br />❑ Denied <br />❑ Sent To Committe <br />Date Certificate Issued: <br />❑ Local Landmark <br />❑ Name of Historic District: <br />Address of Proposed Environmental Change: <br />City, <br />Name of Property Owner(s): <br />Address of Property Owner: <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor's Telephone Number: <br />Current Use of Building: <br />(Print) <br />Application Number <br />NO ❑ <br />Lot Size <br />❑ National Register Listed <br />Township: <br />(Street Number and Street Name) <br />(Vacant - Single Family - Multi -Family - Commercial - Government - etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ New ❑ Building Addition ❑ Landscape <br />❑ Demolition (Completion of Seperate Form Also Required forThis) <br />Description of Proposed Work: <br />Signature of Owner Signature of Contractor <br />