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Application <br />-FOR- <br />Certificate of Appropriatetiess <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 e Email: historicerniclaiana.org <br />Website: http://conunurtitynLichiana.org/historic/ <br />A Certified Local Government <br />r N <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTR1N THIS BOX »»» OFFICE USE ONLY <br />Date Received 0 - - a00 i{ Application Number -2 O O e{ _ 0 10 a- — I +' 1 - <br />Past Reviews: DYES (Dateoflast R vie<u) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />9Local Landmark Fj Local Historic District (Name) <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied E]Tabled ❑ Sent To Committee -Approved and Issued <br />DATE <br />Address of Property for proposed work: s' G, "-f-t . I DD_ * F • <br />Street ,tunker and Street Naive I <br />Name of Property Owner(s): (Please Print) Th'\ k 1 P <br />Address of Property Owner(s): Da 1 bo a-,-1 ► �- <br />1tj <br />ContractorTT <br />Contractor(s) Name: 1nC <br />i� <br />Contract Company Name: - <br />Contractor Address: <br />City: Phone: <br />\D n I <br />Current Use of Building: S) n� `�- �- t k 61 <br />(Single Family -lvfulti-Family - nrnercial - Gotennnent - Industrial -Vacant -etc.) <br />ti..t. <br />Type of Building Construction: 54C _o�11 �CCO-t- �T L�� �3 <br />(SVood Franke - Brick - Stake - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind E] Landscape J2New E] Replacement (,hot in-kind) Demolition <br />(more than one box may be checked) <br />ca 3S alL,m-,nL&rc, <br />n ' 1 <br />Description of Proposed Work: S 15r, L e")-' b V`c� \ ("e <br />L <br />Inu <br />a3 � '• �he� `� � �i� 5,��, ��re �� �o rear' �-� r��- c�v-�. <br />j rr <br />Owner/Contractor. Fax: e-mail �t �elc`� S C�vn 0 CLQ <br />(This office will correspond tvith only one designee) <br />/ ( and/or <br />(Signature of Owner Signature of Contractor <br />— APPLICAT70N REQUIWIEN7S ARE LISTED ON REVERSE SIDE — <br />