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Application <br />4SOUTH B - for - `oyw+ss/otr+ <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />1865 227 West Jefferson Blvd - RM 1123 — South Bend IN 46601-1830 <br />Phone: 219-235-9798 Fax: 219-235-9578 e-mail: historic@michiana.org <br />A Certified Local Government <br />OFFICE USEONLr»»»DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX«««OFFICE USEONLY <br />Date Received 0401 20 0 r Application Number: 200 05-0/ ' �- <br />Past Reviews: , F]YES (D.17£OrLIsrRmEw) lll❑ NO <br />Zoning Type: Lot Size <br />Staff Approval authorized by: Title: <br />Historic Commission Re iew Date: <br />Local Landmark l �ef� �PO4)� n National Landmark <br />National Register District p&._): 1 �� <br />Local Historic District ora...): ((( <br />Certificate of Appropriateness: <br />ElDenied FiTabled Sent To Committee <br />Approved and issued 20 <br />Address of Property for proposed work: n -.)i) 0 (Vt.CJA,.,.nT .�� <br />S...r m -b- orS-1 "a...V <br />City: Sn IA4A •?'v,. r0 <br />Name of Property Owner(s):(rmhrn <br />Township: <br />Address of Property Owner: /.?S S a �t <br />Contractor(s) Name: — S 1 l /I <br />Contract Company Name: __% �(�j/ f� _ Aj S <br />Contractor Address: <br />City: <br />Contractor's Phone No: Owner's Phone No: <br />Current Use of Building: /,da (_P,z //&E2Y <br />(Sb.ru Fo,rdly-M.,TN-Far.dly-Co,..n.vcld•Cord n!•lndusuld-Vr,c/f�-ctc <br />Type of Building Construction: v <br />(Wood Fr-Brkk•S(CN•Sud-Concrdc-OUo) <br />Proposed Work: Inkind El Landscape 0 New ❑ Replacement(al;,.-w,,o <br />(snore than one bas aq be ch,cke,o <br />nDemolition (Completion of Severate Form Also Reouired) <br />Description of Proposed Work: 4W xzz, ,r.. i.ri /•'t[ct a F ><�AF�' c— <br />zQ <br />�/ <br />' ! C c�tt CACP StcsGr SCP / rIGQ",L� /�G4� 4.1�rC <br />� J <br />Owner/Coot ctor: Fax: e-mail: <br />(Thu ogler rl!( ca pad ady duly, ) <br />Signatu weer Signature ofCoptractor <br />APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE. <br />Any and all business of this office Is handled vla e-mail and fax, with least preference to U.S. Mail <br />