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;+ -a <br />Application <br />– FOR – <br />Certificate of Appropriatetiess <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Ufayette Blvd., South Bend, Indiana 466,01 _ <br />Nlailing Address: County -City Buildin South Bend, Indiana 46601 <br />`Phone: 574-235-9793 • Fax: 574-235-9575 • Email: historicCmicluana.org <br />Website: http://conimur-dty.n-dcWina.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT CO,',IPLETE ANY ENTRIES CONTAINED IN THIS UOQ» — OFFICE USE ONLY <br />Date Received 0W`�� Application Numbers D H - 0(P,2 `I <br />Past Reviews: F] YES (Dateof Lao R,-,iav) NO <br />Staff Approval authorized by:Q eyC'L �-- , Title: Q.s-• <br />a U <br />Historic Commission Review Date: <br />Local Landmark F� Local Historic District (Name) <br />E] National Landmark [] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied []Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: �/� �4/f tC ei � <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print).�� <br />Address of Property Owner(s): & ' zxz!- <br />Contractor(s)'Name:r7c �c <br />Owner/Contr ctor. Fax: e-mail <br />;(77tisq/ cee will correspond with only one dcsigur) <br />and/or <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREVEtN7S ARE LISTED ON REVERSE SIDE — <br />(Sing(1Fanzilll-� MMulti-Fmnily <br />{Cmnmercial — Covernnient — Industrial — Vacant <br />— etc.) <br />Type of Building Construction: <br />-(MW Frame — Brick — Stone — Stud — Concrete — Other) <br />Proposed Work: CJ'n-kind <br />❑ Landscape <br />New F_� Replacement (not in-kind) <br />E] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: <br />/'s, <br />7th <br />Owner/Contr ctor. Fax: e-mail <br />;(77tisq/ cee will correspond with only one dcsigur) <br />and/or <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREVEtN7S ARE LISTED ON REVERSE SIDE — <br />