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Applicata <br />- FOR --- <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend da St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax; 574-235-4578 • Email: historic@michiana.org <br />Website: http://commurity.michiana.org/historic/ <br />A Certified Local Government <br />u <br />OFFICE USE ONLY »»» DO NOT COMP ETE NY £NTR7£S CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 91.19/A.003 Application Number _Z o 0 'A . 09 9_1 ^ 3 <br />Past Reviews: []YES (Date of wtivt,.,) [] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 10/a-/03 <br />Local Landmark [] Local Historic District (Name) <br />E] National Landmark [] National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied 0 Tabled ❑ Sent To Committee F1 Approved and Issued <br />DATE <br />Address of Property for proposed work: 7412- `5ci c c v r _ Ave.no e__, <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) JO ((N DXt A^! <br />Address of Property Owncr(s): �'� SE:tsG� � A v e - NU t: <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: SOUTO Bro-1 <br />Phone: <br />Current Use of Building: 5't't es L_15 rAr" t --Y <br />(Single Family - Multi -Family - Commercial - Goaernment - industrial - Vacant - etc.) <br />Type of Building Construction: WOoD geA-S <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work- [i In-kind [] Landscape MNew E] Replacement (not in-kind) C] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: t%OC- O%u2 E OF Fr -our i}0P_Cµ <br />Owner/Contractor. Fax: e-mail <br />(Thu afftce W' mraspond mil oni ne drsis4t) <br />5 <br />�)664-'4_ and/or <br />Signa re of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />