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Application <br />-FOR- <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & 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: liistoric@micliiana.org <br />Website: http://ronunuruhrmicWana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY»»» DODO N-1PLETFANYENTRIES CONTAIN DIN THIS ttnv <br />»»» OFFICE USE ONLY <br />Date Received f'�' 1- p c1 Application Number 0 0_`-i _ /o1 0 <br />Past Reviews: -[ YES (DateolWlReoirw) <br />f- ❑ NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: -670 - 04 <br />Local Landmark )&Local Historic District (Name) t _� W, <br />u,Pis i <br />D National Landmark [] National Register District (Nance) <br />Certificate of Appropriateness: <br />E] Denied F] Tabled El Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />-- �-' Street Number and Street Nanrc <br />Name of Property Owner(s): (Please Print)_ � /,M ff. A- <br />Address of Property Owncr(s) (1, O, <br />Contractors) Name: <br />Contract Company Name: �r) G ��/ % �Udn t ✓1/t <br />J <br />Contractor Address: <br />CitSQv t� GrQ <br />y <br />Phone: <br />Current Use of Building: _ Ell 'Pri 4A <br />091n3le Fannly Multi Faarrly Commercial - Couertmrent - Industrial - Vacant - etc.) <br />Type of Building Construction: ` c <br />GC C9 ,iAi <br />( Wood Frame - Brick - Slone - Steel - Concrete - Other) <br />Proposed Work: [] In-kind Landscape <br />(nrorethnOneboxnmybechecked) P ❑New �Replacement(not in-kind) Demolition <br />'Description of Proposed Work: <br />A <br />W <br />Owner/Contractor. Fax:el 7 <br />(Thisoffice Will correspondtuithonlyonedasign�r) a-mall�('n^�11rf� rS�IrJl n�f' <br />and/or <br />Sign Ire of wtter. <br />Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SID — <br />