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Application <br />, -for- <br />-Ctertycate 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: historicGmiehiana.org <br />A Certified Local Government <br />OFFICE VSEONL/Y»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFF(CE USE ONLY <br />Date Received 20 OCL Application Number: 200$- 0511 <br />Past Reviews: ❑ YES (lursofLaTAEvlaa) NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />❑ Local Landmark ❑ National Landmark <br />A <br />National Register District IN—): Local Historic District p4...): <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee <br />❑ Approved and issued 20 <br />Address of Property for proposed work: J V LoiC o <br />1 so.«h5mb.. e.�.itNawd - <br />City : .:;oLt v�� Q TJ Owner's Phone No: -V 5 � - CA 3 <br />f1 <br />Name of Property Owner(s):(pn/Nn Ma IN � -10 � Y\ � Cc t164 W\ <br />� ` it <br />Address of Property Owner: (rX� 1O 1 rAmm nT\ d 1" ( G C._ -o_ <br />Contractor(s) Name: Y L3 6— kt 111 P . / Z cAy- n l i ijCk <br />Contract Company Name:vQ}idna i <br />Contractor Address: 0 �� �I�_. �?� i C� City: R,.v,; <br />Contractor's Phone No:opikgo, C14G - <br />Current Use of Building: �F(A Yj t V <br />(Siegle Family-,W4i-Family-Clmmeli t-Gov¢rrment-/nda«,ial-Vacant-ata <br />Type of Building Construction: (A 1l7(I CA Q <br />(woo/Fi.me-enck-Stora-S/s«:Conc«e-otpa) . <br />Proposed Work: ❑ Inkind ❑ Landscape ❑ New ❑ Replacement(narn-kind) <br />(mors than one box maybe checked) ❑ <br />Demolition <br />((�'pp' <br />Description of Proposed Work: <br />Owner/Contractor: Fax: e-mail: <br />(This oflin *H corrupond with only one designee) <br />I <br />Signature of O ter Signature of Contractor qfj VA,.f <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />