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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-Cih Building, South Bend, Indiariu146601 <br />Phone: 574-235-9798 • Fax: 574-23.5-9578 - Email: historic@nruchiana.org <br />Website: http://Conlmunity.rnichiana.oro/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED <br />IN THIS Rnx »»» OFFICE USE ONLY <br />Date Received it - 01 - D 4 Application Number A o O Y- H 0 I <br />Past Reviews: YES (Date ofLtst Pwri«, <br />Staff Approval authorized by: <br />Historic Commission Review Date: NcJ . 15, 2OUq <br />[1 NO <br />Title: <br />Local Landmark Local Historic District (Name) Pa, Jr <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />M Denied E] Tabled E] Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: I OLS" MVdS ed .9yEN �c <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) DVOC L 03 /ILRN - ZdSC../ <br />Address of Property Owner(s): 1 C , 3r H V J.S f <br />Contractor(s) Name: 11 C -U C 7 <br />Contract Company Name: F'CcCt i Lrl�yscn:'e ; nc <br />Contractor Address: S.21 IS- IVB, <br />City: _ SCC fit 1?'�,vr .' z,U fl!1$ Phone: S -7y5 - <br />Current Use of Building: jCG S%• Ori 7?/9t- s I,J�•;4_� f'r?rn?tr <br />(Single Family — Multi -Family — Commercial — Qvernment — Industrial — <br />Vacant —etc.) <br />Type of Building Construction: <br />(Wood France - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: Ej In-kind 2 Landscape [] New [:] Replacement (not in-kind) E] Demolition <br />(wore than one lox !?jail be checked) <br />Description of Proposed Work: Pte146 siiC 1977.9cNED <br />Owner/ ontractor Fax: —e-mail rtrk► f zw� .,� I rcnv �c►- <br />(This ofF • 1 correspond wi <br />th only one desiimee) <br />and/or <br />Sigttabt f butter Signature of Contractor <br />— APPLICATION REQLIIRVVfEN7S ARE LISTED ON REVERSE SIDE — <br />