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�SOUTR � Application <br /> 'x _ FOR — <br /> Q" Certificate of Appropriateness t OS <br /> Historic Preservation Commission of South Bend&St.Joseph County 0 o <br /> 125 S.Lafayette Blvd.,South[lend,Indiana 46601 .0 <br /> l86S Mailing Address:County-City Building,South Bend,hidiana 46601 <br /> Phone:574-235-9798 • Fax:574-235-9578 • Email:historic@micluana.org <br /> Website:http://community.nticWina.org/Iiistoric/ <br /> A Certified Local Government <br /> OFFICE USE ONLY—»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOA,, —OFFICE USE ONLY <br /> Date Received 08-04- t q Application gNumber s o o 0 e 0 y <br /> Past Reviews: 1Q YES(Date ofLast Revinv) O�il /12— NO . <br /> Staff Approval authorized by, / Title: <br /> Historic Commission Review Date: 0200 <br /> ,Local Landmark ❑Local Historic District(Name) <br /> I]National Landmark I]National Register District(Nance) <br /> Certificate of Appropriateness: <br /> Denied []Tabled E]Sent To Committee E]Approved and Issued <br /> Q/ <br /> DATE <br /> 1'2 <br /> Address of Property for proposed work: U/�1 U tL' I `' l C/1,11 ko . <br /> ,v <br /> Street <br /> /Number and Street Name <br /> Name of Property Owner(s):(Please Print) K <br /> Address of Property Owner(s): lL'(��U i� •�C1 y1 j . <br /> Contractor(s)Name: (�ka(-/i <br /> Contract Company Name: <br /> Contractor Address: DA 'o m 13 ��? <br /> City:/ Gj Lt(0Vi !� Phone: 3— 't d 07 <br /> Current Use of Building: �� n Gj t� -rc, <br /> (Si a Fatuity-Multi-Family- onmrercial-Government-Industrial-Vacant-etc.) <br /> Type of Building Construction: - (,11ty <br /> nl)d � -0 YYle <br /> (Wood Frame-Brick-Stere-Steel-Concrete-Other) <br /> Proposed Work: Ej In-kind Landscape . I�Ne-,y I]Replacement(not in-kind) Demolition <br /> (more than one box may be.checked) �dl .H ori <br /> Description of Proposed Work: <br /> (Oe w es Lt )' Re -D a 0/1 4v 4-he <br /> W D(,i U ct 15 o Il k e 4-o rte,is f 4-he Cx 1.5 ti v'- ►/a be ��o <br /> Owner/Contractor. Fax: e-mail <br /> (This office will correspond with on[ one designee) <br /> - and/or <br /> S' ature of Owner Signature of Contractor �t� <br /> APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE YG(I <br />