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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 />iVlailing Address: County -City Building, South Bend, Indiana 16601 <br />Phone: 574-235-9798 • Fax:574.235-9578 • Email: historicCimichiana.org <br />I''ebsite: littp://con-Lniuriity.niicliiitii.org/Iiistoric/ <br />A Certified Local Government <br />OFFICE USE ONLY—-- DO NOT CO VPLETE ANY ENTRIES CONTAINED N THIS BOY --—OFFICE USE ONLY <br />Date Received <br />Past Reviews: [:]YES (Date of Ust lienicto) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />Application Number — — — — - <br />Local Landmark Local Historic District (Name) _ <br />National Landmark National Register District (Nance) <br />Certificate of Appropriateness: <br />NO <br />Title: <br />❑ Denied E] Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: I ( ) q� RIVct-St C/ Di IV i <br />j, nnStreetNunberand Street Name <br />Name of Property Owner(s): (Please Print) �n 4,O ` 1 _ C) C e <br />Address of Property Owner(s): c�sa f \ ` 1 <br />Contractor(s) Name: I& In �7tPe' <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Current Use of Building: <br />Type of Building Construction: <br />Phone: <br />U (Single Family r /Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />( Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: 0 -In-kind F] Landscape E] New SKReplacement (met in-kind) [:] Demolition <br />(more than one box may be checked) I ( c <br />Description of Proposed Work: /1�AgI—I'ti�' TfCtC�t1Sa�� <br />a !D(Ctce/)^Clti� O� CtlVtYlcnt (►�-�(<�1 �X �r'tr�n/ S���/Kn SU SE°Y) <br />31 kck((acg%zijk G� C�t 4Y1111LYh (G�( tci st-,rm CAJ 61 G,/se's C/te4l.0gf <br />nC/�s�����ss <br />Owner/Contractor. Fax: e-mail �� f��1nG4t}C ft�SSt�� <br />(Tris office will correspond with only one designee) <br />` <br />(Z() �Y�--�J�Z.G[� and/or <br />Sigiiature of Owner Signature of Contractor <br />— APPLICATION REQUIREVE,NTS ARE LISTED ON REVERSE SIDE — <br />