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Application <br />- for - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />227 West Jefferson Blvd - South Bend IN 46601-1830 <br />Phone: 219-235-9798 Fax: 219-235-9578 e-mail: historic@ntichiana.org <br />A Certified Local Government <br />OFFICE USE ONLY»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS SOX«««(TFFICE USE ONLY <br />Date Received i f t% 20 Q1.,,,_ <br />Past Reviews: YES 1rU760FtASTRSM" <br />Staff Approval authorized by: PLW� <br />Application Number. 2011, O/O t/ <br />❑ NO <br />Title:lf . <br />Historic Commission Review Date: I 11-A02- <br />❑ Local Landmark ❑ National Landmark <br />❑ National Register District (Name): <br />R1Local Historic District(Nem-): -r(— <br />Certificate <br />( <br />Certificate of Appropriateness: <br />❑ Denied <br />❑ Approved and issued <br />❑ Tabled ❑ Sent To Committee <br />20 <br />Address of Property for proposed work:b' E 4 \ div00 ! 64--. <br />�dea Number eeulSre.rN e) <br />City; )C)k r�-�r._C� Owner's Phone No: <br />Name of Property Owners):mRm {i ` ifiQ�i- 1 t—� —"r .A— r <br />Address of Property Owner: L? 1 lZ 1,�1 ME <br />uta DSS <br />Con#ractor(s)Name: <br />Contract Company Name: R -,(,\/,1S \Ao' <br />Contractor Address: C. -M \1? -x City: <br />Contractor's Phone No( f �Yi " n�Ci s <br />Current Use of Building: 5i1- `U_— Sa <br />(Single F +�,y�•_Hu Family • Cnmmerdat • ernment - /nduetrid - ('�Icnnt• da <br />Type of Building Construction:_„ xx7c1�'or, <br />(Wood F}eme+Brio -Blau. Steil-Conuete-C7lhn) <br />Proposed Work: ❑ Inkind ❑ Landscape LLI New ❑ Replacement(naeln-kid) <br />(more than one bar maybe checked) <br />De olitian <br />Description of Proposed rk:()rpsE lc~ <br />tIL <br />d t �at 1 <br />Garr 5 ifs (e & +,herr/ 60 e Q/�/lti d d t if? -2 AVC(9nr i,Wrs oo/ �t"`ar <br />',� w >ftfM )5a1kS1fcc{!S °t S1^ per/ r,, IS . r S}ti j/ Wvn &r leer �tcKS <br />QcS� t �,�uS(fcoGf, 5k+�tcfl�t/�S R+ta`rf5 �e�Jb+itb% C�+t�tP <br />tv <br />q n ,' <br />12`Xza' �nelC�ontrattor✓. F I:� w !n�"� a -mail: k4 <br />(Thu oJfin will corrmpond with only one designee) <br />Signature of Owner <br />X--. - - � /5" , /.//, "' <br />Signa re of ontracto J� <br />� -'� '7 <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />