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Application <br />- FOR - <br />Certcficate of Appropriateness <br />Historic Preservation Commission of South Bend do St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: Countyr"rty Building, South Bend, Indiana 46601 <br />Phone. 574 - 235-9798 • Fax: S74- 2359578 a Email: hiutoric0michiarmorg <br />Websitr. http: / /commurdtyrrichiana.org /historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPL A E N77ZIES CONT TNFD IN THIS BOX » »» OFFICE USE ONLY <br />Date Received A l - Zl' - Application Number .9 . 9 o 1- D %o <br />Past Reviews: RYES (DNteofLi.ttteof w) .7 E] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date - .Z CO3 <br />Local Landmark Local Historic District (Name) <br />0 National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />F] Denied C] Tabled F] Sent To Committee F1 Approved and Issued <br />DATE <br />Address of Property for proposed work: ` ZS LJ • N OYtJ1 .b 0M V y - <br />Street Number and Stmt Name <br />Name of Property Owner(s): (Please Print) Yr�'-+ �• $- �Ct tlu�r ne, s. �a.W <br />Address of Property Owner(s): <br />Contractor(s) Name: w °vlL J Lt <br />set."t 0-3 cLboYt_ <br />3. � � - f ✓ i a'! �� 1N�1 <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: s► n t✓ �Cirn i q <br />inglrFamily Multi - Family— Commercial — Government — Industrial— Vacant —etc.) . <br />Type of Building Construction: r i cl<. / St�,"CCO <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: �In - kind ❑ Landscape F] New Replacement (not in E3 Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Pl cLI+CLC-1-i'ek 5)'e et neat CCr-A ,J i ri q <br />Owner/Contractor. Fax: <br />(Thus office will cmrgvnd with only oar desipw) <br />e -mail 13n yyy-:t t % ) (a>, HA - CJL- <br />Kt -x`1' and /or <br />igtta re of Owner Signature of Contractor <br />— APPUCA77ON REQEHREMENTS ARE LISTED ON REVERSE SIDE — <br />