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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 - RM 1123 — South Bend IN 46601 -1830 <br />Phone: 219 -235 -9798 Fax: 219 - 235 -9578 a -mall: historic @michiana.org <br />A Certified Local Government <br />OFFICE USE ONLY» » »DO NOT COMPLETE ANY ENTRIES CONTAINED IN TiIIS BO�X<< <<< «OFFICE USE ONLY <br />Date Received 200 _ Application Number: 200v- t7 (v 0 <br />Past Reviews: YES (DATr ❑ NO <br />Zoning Type: Lui Size <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: A n /7' , 2-00 7 <br />❑ Loal landmark ❑ National Landmark <br />❑ National Register District (N..)- <br />Local Historic District ov. 0 Cc, 5 cv ltr <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee <br />❑ Approved and issued <br />I0 <br />Address of Property for proposed work: <br />City :/ Township: <br />Name of Property Owner(s):(PWM � [ q 1A <br />Address of Property Owner : ,�/ .� ��f� i_ . 7 "� �� 1 <br />Contractor(s) Name: /A (4 <br />Contract Company Name: <br />Contractor Address: <br />Contractor's Phone No: <br />City: <br />Owner's Phone No: <br />Current Use of Building: <br />(suzrr F..ur - Meur•r..ur - ea.e.rrc(et • c. wne.rN . tedrxn.r . v.cewr - ero <br />Type of Building Construction: <br />(Wool Pne.e - edc! • Sreer •Sad • Ceerrrre • pier) <br />Proposed Work: ❑ Inkind ® Landscape ❑ New ❑ Replacementt.al.•u,a <br />(—v thm o.e bw my be cbrctad) <br />❑ Demolition (Completion orSeoerate Form Also Renui / red) <br />Description of Proposed Work: <br />/ ✓ <br />Owner /Contractor: Fax: Z-:? 7 6c7D a -mall: <br />(rw0,01ce.tano.r p.r.ui me dara. «) <br />ignatu o Ownner Signature of Contractor <br />J <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />Any and all business of the office Is handled via a -mail and fax, With least preference to U.S. Mail <br />