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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 • Emaik historicamicluana.org <br />Website:httEy//community.rnichiana.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 (,P - ().2' ZUO�l Application Number 2 0 o e( p & 02 <br />Fast Reviews: ❑ YES (o tta/t.rst liMew) ONO <br />Staff ApprovaLauthorized by: Title: <br />Historic Commission Review Date: A <br />Local Landmark Local Historic District (Name) l` i ^C o(n wes• t t�* f- <br />0 National Landmark ❑ National Register District (Name) <br />U <br />Certificate of Appropriateness: <br />0 Denied ❑ Tabled M Sent To Committee Q Approved and Issued <br />DATE <br />Address of Property for proposed work <br />i Street Number and Stmt Name <br />Name of Property Owner(s): (Pleze Print)=1_6t�. •v n t rra.s o t <br />Address of Property Owner(s): 1t5+ - 2�. t L'tfhY E 4T <br />Contractor(s) Name: a% M A N r, A 46Z A i;, -;Q <br />Contract Company Name:Z A L,- t4 ant <br />Contractor Address: <br />City: r r r - r- %l F xtt, Phone: <br />Current Use of Building: � j+ 121? X i 5-r r= 4.1 O U _< i <br />(Single Family- Multi.Famrty-Commercial -Government - Industrial -Vacant -etc.) <br />Type of Building Construction: <br />( Wood Pramt - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: k] In-kind 0 Landscape O New [3 Replacement (not in-kind) 0 Demolition <br />(more than one Bus may be checked) / <br />Description of Proposed Work Z 6Th, 7- tLSA, I F t s> r ug C d C <br />VA e ArT— S. ",L,AZI To -Ariye-9' kErAI L _ <br />Trho D rF AAl^ � 7On <br />D bot V 0A PWrr .17-67 M OY F: r_>= -r•A l 1 < <br />Owner/Contractor. Fax: -7A4 - G -3-C-3 e-mail .. <br />(71it of a will wnespond with only one designee) <br />and/ori <br />Signature of Owner j ghature of Contractor <br />_ APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />