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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 ' F=574-235-9578 • Emal- historicemichiana.org <br />Website-hapWoommuni tychiana.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 OS-- 0l ` 2 00q Application Number a O 4 y _ OSO 1 <br />Past Reviews: YES (Date q ixt Fruiew) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: r"t a `?" f ZOO' <br />[� Local Landmark Local Historic District (Name) Kt tlatLSlDI_ p2t <br />C] National Landmark [] National Register District (Name) <br />Certificate of Appropriateness: <br />[] Denied [] Tabled 0 Sent To Committee ❑ Approved and Issued <br />PATE <br />Address of Property for proposed work: O 1l �'� ���(�� <br />r Street Number and Name <br />Name of Property Owner(s): (Please Print) L Rwemc,", Oa`J..rA Cu h0 <br />` am <br />Address of Property Owner(s): q + e -�>r'} qP _ <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: NOTA a 1 �+_" Phone: 1 <br />Current Use of Building: 1 � O i A 1 1V tomIn S 'Ae qQ-� ��vl Us -d. �y <br />(SingleFamily— Multi-Family—Commercial—Govermr nt Industra(—anete� <br />WZ <br />Type of BuildingC(\nstf ction: <br />\ 0 _t.t ay -n o (Wood Frame) Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: 11 ``C] In-kind. [C Landscape KNew Replacement (not in-kind) PfDemotition <br />(more than one box may be chn cd d) <br />Description of Proposed Work: C��:�iY t'1 OY1 d- -�D 7Jt? ^ re !�13G2 1�4t/1 <br />! 7C.Vt�a 'i�e zt1C F `� c._ Y2�1 a.c. / <br />I <br />.w AAj, Qs C' a.� as �0 ski f� tvtce w> <br />or t X15 2 vw " o a Yi 140MJ <br />;d. <br />J i T �y1 Vi f iX+ �— f�-'Va C/�.�...J Ir"""e 03sIb0 k -- - d cuhnirl us , P .�Ownnt ctor, Fax: e-mail <br />(Tin u wilt mrnspand wit one deli � /'7 <br />and/or <br />r% Sigriatu o wner"I y Signature of Contractor <br />— APPLICA 6N REQUIREXfEVTS ARE LISTED ON REVERSE SIDE — <br />