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Application <br />-FOR- <br />Certificate of Appropriatetiess <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: 574-2359748 • Fax: 574-235-9578 • Email: historicQrnichiana.org <br />Website: http://conunurtity.n-dcWana.org/Wstoric/ <br />A Certified Local Government <br />OFFICE USE ONLY >>>>>> DO NOT COMPLETE ANY ENTRiEs CONT LINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 03/07/"-001 Application Number -�- o - ` - 020Y <br />Past Reviews: ❑ YES (Dateaf Lm Rerirw) �N0 <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark M Local Historic District (Name) <br />❑ National Landmark n National Register District (Name) <br />Certificate of Appropriateness: <br />F] Denied E]Tabled n Sent To Committee []Approved and Issued <br />DATE <br />,riF_k' �LLV%LQ,u� t <br />Address of Property for proposed work: l *MF-7FAi r Ro,i.� <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) L-rrl M I c:N.uG„ <br />Address of Property Owner(s): /77.x- �_r—tPLI'1^ z w'o -7-.. U� <br />Contractor(s) Name: it <br />Contract Company Name: Sj Xi- L,.44.:r, n+.ei= <br />Contractor Address: 17l cb —�_ Yet= T n <br />City: SaJ"' , r(2- -rev Vf b{b Phone: 2�7q - 2 W -7.7r 7 <br />Current Use of Building: <br />t(Si gle Family - Multi -Family - Commercial - Government - Industria( - Vacant - etc.) <br />Type of Building Construction: N A <br />� (Wood Franc -Brick -Stone - Steel - Concrete -Other) <br />Proposed Work: [] In-kindLandscape / New � Replacement (not in-kind) []Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Lf nf `77 <br />ffN G.r�t r✓S . !t.,/GL Di ¢ri1 <br />Owner/Contractor. Fax- '41q- 7'iL - 1 `i Ss e-mail <br />(This once will mrreslond,,with only one designee) � <br />4;D W4 <br />and/or / <br />Signature of Owner Si a re of Contractor _ <br />— APPLICAT70N REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />