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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 • Fav -574-235-9578 - Eiiiail:liibtofic@znici-dani.org <br />Website: http://commurdty.micWini.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY —>» c IN THIS BO t »»» OFFICE USE ONLY <br />Date Received 01//& "04 Application Number0 <br />Past Reviews: ❑ YES (Nteo/tsst ita ru) ❑ NO <br />Staff Approval authorized by: f Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District (Name) <br />[} National Landmark n National Register District (Name) <br />Certificate of Appropriateness: <br />[] Denied n Tabled [] Sent To Committee [] Approved and Issued <br />DATE <br />(4.) <br />Address of Property for proposed work: t <br />Street Nundwrr�a�n(d Street Name <br />Name of Property Owner(s): (Please Print) — YL) 1��t"t i� r ,' "t �4n (-� <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name:'— <br />Contractor Address: tA �� }—' T�-ti <br />—`' , ll r 4 } <br />City: .>O �"\ -(\ EJh IIv �G o I Phone: �" 57 <br />Current Use of Building: <br />(Single Farnily - Multi -Fart' ly - Conikercial - Gowrinnod - Industrial - Vacant - etc.) <br />LA <br />Type of Building Constructior4 <br />(WcodFnunc-Brick-Stone-Steel-Concrete-Other) <br />Proposed Work:] In-kind [] Landscape New E] Replacement (not in-kind) [] Demolition <br />(more than one tax may be clucked) <br />Description of Proposed Work: <br />OLkA <br />J <br />1 `' cz•w4__ ,��. �� - ftp a Dpi <br />• -�L &,vaoL <br />Owner/Contractor. Fax: 5-7L - a3 E 666 e-mail(—'(This office will cormspond with only one designee) <br />q. t442 t)� and/or <br />t Signature of Owner Signature of Contractor <br />— APPUCA77ON REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />