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Application'' ku <br />- FOR - J V <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />IVlailing Address: CUllnty-Clty Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 Email: historic@n-dchiana.org <br />Website: http://communityn- ichiana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE A1W ENTRIES CON ITATArED IN 77U SOX »»» OFFICE L1SE ONLY <br />Date Received- 0`l ' Z`I. O Z O a _ 09 <br />Application Number — _ 7 �► <br />Past Reviews: ❑ YES (Date gflnstRmiew)[NO <br />Staff Approval authorized by: /Q Title: <br />Historic Commission Review Date: ` u� <br />i <br />Local Landmark Local Historic District (Natne) <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied Q Tabled Sent To Committee E] Approved and Issued <br />DATE <br />�ir� S o /�:• ..� 1 ��66/. <br />Address of Property for proposed work: <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s)n: e6!2& SD <br />Contractor(s) Name: 7W ,[/ 11- <br />Contract Company Name: <br />Contractor Addr( !r <br />City: <br />Current Use of B <br />Type of Building <br />R7er and Street Name <br />6 ' <br />Proposed Work: F] In-kind E] Landscape CaNew Ej Replacement (not in-kind) Demolition <br />(more than one box may be clucked <br />Description of Proposed W rk: <br />G Ea f- !n+ <br />f l <br />-%,/7 OD . -j- . ii V - , / ., <br />Owner/Contractor. Fax: 7q Z-3-952-2— e-mail_ /�►�!`�t�r�-�.t�l�cd/1nG�S ���'I <br />(Pins office mill cones and with only mt due dere �iee) <br />and /or <br />titre 2et� o %fsr�.R _ Signature of Contractor <br />- APPLICATTOt\T REQUIREMENTS ARELISTID O1�iREVERSE SIDE — <br />I -J MajewzoeA eijeW dTE=EO -tO 62 JOS <br />