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\1 <br />Applicatim <br />-FOR- <br />Certificate 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: County -City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235.9578 • Email: historicOmichiana.org <br />Website: http:/%communitymichlana.org /historic/ . <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »>»> OFFICE USE ONLY <br />Date Received 1i-01-©3 Application Numberl a c' 3 - toN <br />Past Reviews:`�] YES (L)vtroJtnrt ttrviw) c1- IH'al ' '1�?_000• NO <br />7~ Lo j "Loo 911,1 <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: FO - aO' 03 <br />10, Local Landmark Local Historic District Wame) <br />'VLNational Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied [] Tabled [) Sent To Committee [:]Approved and Issued <br />DATE <br />Address of Property for proposed work: _ .t / f n tey e) k& V <br />�lfes/ <br />Street Number and <br />pStreet N,am�e <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): 1 C.'.�/e �C�//?trelAw/tv Lt'ir <br />Contractor(s) Name: :j),4L"-- <br />Contract <br />Company Name: <br />Contractor Address: � -7� ��r -S !� <br />City: ��/��/fi ,�„ �T_�11��„� Phone: <br />Current Use of Building: 47 <br />(Single Family - Multi -Family - Commercial - Government - industrial - Vacant - etc.) <br />Type of Building Construction: 6 1 f S "7`t; � I - — t t% l.� %/- <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: M In-kind [K�Zandscape (:]New i] Replacement (not in-kind) n Demolition <br />(mon than one box may be checked) <br />Description of Proposed Work: <br />Owner/Contractor. Fax: e-mail F�ntl!-�l683��u2� C)CJr>7 <br />(This n v ll correspond with only one designee) <br />lAignaturAofOwner <br />and/or <br />Signature of Contractor <br />— APPUCA77ON REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />