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Application <br />- <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, SouthBend, hidiana 46601 <br />Phone: 574-235-9798 • Fax:574235-9578 • Email: historinicluana.org <br />Website: http://commurtity.micliiana.org/historic/ <br />JF.. \ <br />A Certified Local Government <br />OFFICE USE ONLY—»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS 00X >-—OFFICE USE ONLY <br />Date Received C1-03- C) Application Numbero- ° 0'I - 0503-1 <br />Past Reviews: [:] YES (Vale of Ust Rcviczo) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />10� <br />Title: <br />Ej Local Landmark Local Historic District (Nano) gd jf--L"�Tlac� <br />E] National Landmark F] National Register District (Name) Q <br />Certificate of Appropriateness: <br />❑ Denied [] Tabled ❑ Sent To Committee E] Approved and Issued <br />• DATE <br />04�/-�1o�0 K / <br />Address of Property for proposed work: <br />/ / Street Number and Street Name <br />Name of Property Owner(s): (Please Print) (�P�`�;Z,4um_ <br />` '/52- z <br />Address of Property Owner(s): {V ej d' -f 0,.,) C <br />Contractor(s) Name: — ��e 1� <br />Contract Company Name: 6,12 <br />Contractor Address: 7�0/t <br />City: 'rB y/ T7 Phone: ��LlZ�c3 <br />Current Use of Building: <br />(Single Fmnil y — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: ezg= <br />( od Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: In-kind ❑ Landscape [] New (X Replacement (not in-kind) E] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: c a <br />�a®_r Aut r.l/S'/�NosT Ne C��5�.aZ <br />A%4VQ aPry Ptnn_Ne1L4 k_EoNce-2r <br />Owner/Contractor. Fax: e-mail <br />(This office will correspond with only one dcsignce) <br />nd/or <br />Signature o mer Signature of Contractor <br />— APPLICATION REQUIRENIENTS ARE LISTED ON REVERSE SIDE — <br />