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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 Fax: 574-235-9578 • Email: historic@micluana.org <br />Website http://mmmunitymichiana.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 10 -13- Z Oo q Application Number O p i - /013 <br />Past Reviews: YES (Da,ea/lazr Revieru) NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: " <br />Local Landmark Local Historic District (Name) TAY1_Oa'S Et,D <br />National Landmark E3National Register District (Name) <br />Certificate of Appropriateness: <br />Q Denied E] Tabled Sent To Committee E] Approved and Issued <br />DATE <br />q cr <br />Address of Property for proposed work: J Io � SU(d. ? Drect <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) (1,11Jer l 21 N:td r-c� Hicbe rl <br />Address of Property Owner(s): '316 S�'��% �t -ee L , �oc441; Herhr/ ; IN [161.01 <br />Contractor(s) Name: HQrelri On' er Tcisiie.� �CIt1sOS <br />Contract Company Name: C: -t �IZ� Ncut�S hESsc�P���ip l 1 Ci1Cre le <br />Contra ctorAddress: O4CC keel It ala akwl1 1 !11,53(., 151'7 N. Kenmore; S. Bend, IN 41 2f <br />L.iK2� lle 5-7q- 7$ii- q72(, <br />City: ��{11 " Fie t� d Phone: .7?4 -2,s'] -1$!5 <br />Current Use of Building: (1) Farm I <br />(Single Fantt- Multi-Fanrity - Commercial - Government - Industrial - Vacant -etc.) <br />Type of Building Construction: IA lborl F(Gst')_ <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: E] In-kind [] Landscape 0 New E] Replacement (not in-kind) E] Demolition <br />(more than one box nay be checked) <br />Description of Proposed Work: Ur,'Aruc4 U 24' (20' ,rp -e r,r) <br />!ilot)G w�1h eonCre}e Cir,JP ihat Will lc4.6 arrtd IPA wren -#o 4kG <br />a kkeY <br />Owner/Contractor. "Fax• 5`7�Vg- e-mail 1140ocale1jrfntA•C:enl <br />Was officr will torts nd wit! ly o designee) <br />and/or <br />Signature of Owner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />