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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 Build'uig South Bend, htdiana 46601 <br />Phone: 574235-9798 • Fax:574-235-9578 • Email: historic0micluana.org <br />Website: http://commurity.n-dcWana.org/ltistoric/ <br />A Certified Local Government <br />OFFICE USE ONLY-»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received O9 - D3 - 2.004 Application Numbet-!L o e `-- 09 b 3 -Z <br />Past Reviews: DYES E] NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: p1_ .20- 0 <br />Local Landmark Local Historic District (Nance) Ed gevja-frs -Drive, <br />❑ National Landmark ❑ National Register District (Nance) <br />Certificate of Appropriateness: <br />❑ Denied []Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />r/moo/o K 45`9 <br />Address of Property for proposed work: 4Z` 4 &dAt r..l fT <br />Street Nwnber and Street Name <br />Name of Property Owner(s): (Please Print) Rt'/jJ/a <br />Address of Property Owner(s): a/1r4Q ro*l C 7- <br />Contractor( <br />s) Name: <br />tge0A)eit o?en #/oar cC <br />Contract Company Name: .�/.9/cam �G(%��P /,S'Ana�ZIIYPanC r4 CDaf7AAeTsn. <br />Contractor Address: 17y�fV h e y1,iD w CZ_ <br />e <br />Current Use of Building: <br />Phone: <br />(Single Family -Multi-Fmnily - Conrercinl - Government - Industrials- jVacant - etc.) <br />Type of Building Construction: CO && D AIM Al <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: In-kind andscape [c Kew replacement (not in-kind) [] Demolition <br />Onore than one box may be checked) <br />Description of Proposed Work: AAD Q?e/,6% &K_2 7- <br />Owner/Contractor. <br />Owner/Contractor. Fax: e-mail <br />(This office will c ad with on! or lcsign <br />_ and/or <br />AV Signature of Owner <br />Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />