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Application°MM%tso°Ne., <br />- FOR - <br />Certificate of Appropriateness t <br />Historic Preservation Commission of South Bend & St. Joseph County `oma <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address County City Building, South Bend, Indiana 46601 <br />Phone: 574235-9798 • F=574-235-9578 • EmaiL• historic@michiana.org 5 s ? D <br />Website: http://communitymichiana.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 6 ' 03 . ZOOy Application Number 1 t7 ' `f _ O(a 03 <br />Past Reviews: F] YES (vote o/tnstiteoim) [] NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: ITU n4 -2(t ZOUq <br />Local Landmark Local Historic District (Name) 6—DC)xi✓ tN /{TE l - <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: ; <br />C] Denied E] Tabled ❑ Sent To Committee E] Approved and Issued <br />DATE <br />Address of Property for proposed work:/�4C7�✓91CiC_ <br />If Street Amber and Street Name <br />Name of Property Owner(s): (Please Print)r.1aM,�g� <br />Address of Property Owner(s): <br />Contractor(s) Name: Ul.✓&L-el— <br />Contract Company Name: <br />Contractor Address: <br />City:�SO. 1?s.h T..J Phone: <br />Current Use of Building: A44(P <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: _Ldo /J /teK- <br />(Wood Frame —Brick —�epe—St — Concrete— Other) <br />Proposed Work: ❑ In-kind ❑ Landscape New lacement (not in-kind) Demolition <br />(more than one box may brchecked) 77n,%9 PtTGF} * ICE- Roof (rttlpet19 <br />n <br />Description of Proposed Work: / �r %Jpu-�>•' `; P.tf.� jo/.�l�ow+t_ rrP�"ca in- <br />Y� /7 k;n4 -11 <br />/(.W(o G /�1Jju Q riot <br />�_fr !t/.on_ Rtsvl(3CE 1N-KtN As <<ori� <br />As 'PosSl6t-F_ . <br />0 <br />Owner/Contractor. Fax: e-mail <br />(This office will correspond with only one designee) <br />� A. <br />a0� and/or <br />Si ature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />