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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 9 Email: historic@micluana.org <br />Website: http://commurtitymicliiana.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 - q_�G6 Application Number d I-V- �'2 <br />Past Reviews: YES (Date of cast Review) E] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 2 Oo y <br />Local Landmark ❑ Local Historic District (Name) <br />J&ational Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied [] Tabled E] Sent To Committee Approved and Issued - .200/ <br />DATE <br />Address of Property for proposed work: f' eo e.- <br />1 Street Number and Street Name <br />Name of Property Owner(s): (Please Print) �► • t1 0f _!�©ced4 9110d <br />!/�C�te n - �� 1 �/W . 57&e,Address of Property : , %���t�l y�oL <br />P Y Owner(s �) � <br />Contractor(s) Name: <br />Contract Company Name: 7;Da�.'a0 <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: 7 e erea ��b�'� 4� `" <br />(Single Family —'Multi -Family — Commercial — Government —Industrial —Vacant —etc.) <br />Type of Building Construction: ,ee xr.;-t.5zo a -Z^1 4ecel re/)4r_e l eey,� <br />(Wood Frame — Brick — Stone — S4— Concrete — Other) <br />Proposed Work: E] In-kind n Landscape' E] New 0 Replacement (not in-kind) n Demolition <br />(more titan one box may be checked) <br />Description of Proposed Work: lee- j" c e C bl1a OS eW ,,S C�c J�/ -s e, / eAA,0� <br />cvxG/ wl�li /'e%n,�rce�PC�tee�0 wi%i ����, Flo,-rre� ru��/>✓ <br />L e�q fir' yea So u/�Li <br />U <br />•e �62Cec� 'It A e A UC P 711 P 1"14 >'eto rP��� �ea�,, Selo <br />Owner/Contractor: Fax: /sly) x,35_-9171 e-mail G �y`P�@Ci'•S� »!i'I • �-s <br />(This office tai espond with only on ignee) <br />h and ��1 /iLt �• <br />Signature of Ownerignature of Contractor <br />ON REVERSE SIDE — <br />APPLICATION REQUIREMENTS ARE LISTED O <br />