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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, htdiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email: histori as tichiana.org <br />Website: http://commurdty.micWani.org/historic/ <br />A Certified Local Government <br />R - h <br />OFFICE USE ONLY—»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS 130,'K »»» OFFICE USE ONLY <br />Date Received 0-'2-- X00 Ll Application Number,2 O O q _ 0/ o.? — + <br />Past Reviews: ❑ YES (Date of Last Review) F-1 NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />9Local Landmark [:]Local Historic District (.name) <br />National Landmark F� National Register District (Name) <br />Certificate of Appropriateness: <br />F]Denied [-] Tabled []Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: �� �' G7 - 1 d �)- :7- 1= " � I <br />J (I 1 Street ;('umber and Street Naive I <br />Name of Property Owner(s): (Please Print) 1 ht\ `1 P C A�G I ZZ <br />Address of Property Owner(s): Da a , 0-6.I r' <br />Contractor(s) Name: 1` �i1 e'> T 4Ct CIAW ' O Scco � I �� L <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />, \0 � n j . <br />Current Use of Building: S l n� `� LM' L + kG f'r-y �� <br />S1 in S1 <br />(Single Fatuity - Multi -Fancily - Linercial - Gocernrnent - Industrial - Vacant - etc.) <br />Type of Building Construction: C_CO A_ T C_ <br />(kod Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: 0 In-kind I] Landscape j2'1Cew ❑ Replacement (not in-kind) ElDemolition <br />(more Own one box nmy be checked) CCz S,{ <br />r I <br />Description of Proposed Work: <br />U �cs Cis uC2 �YD��r �c rr T� 0&�'i Obi <br />X ice, Y-\ A,\(�e�t���(� <br />ll II t <br />Owner/Contractor. Fax: e-mail <br />(This office will correspond with only one designee) <br />I' and/or <br />(Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />