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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: 574-2359578 • Email: SBSJCHPC®co.st-joseph.in.us <br />Website: http://www.stjosephcountyindiana.com/sjchp/index.htn-d <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX '»»> OFFICE USE ONLY <br />Date Received / Z/2-/zo e-5' Application Number of a 0, /e?o-Z <br />Past Reviews: ❑ YES (Dateaf LO R,: i,,,) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />❑ Local Landmark] Local Historic District (Name) ' " `' " <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DAT[ <br />Address of Property for proposed work: I 1 I Z W "` l V'_C C. - . <br />_ L1 ' Street Number and Street Name <br />T <br />Name of Property Owner(s): (Plen;c Print) OIA ti S 111 , Kc, k. TWJI!" <br />II" <br />Address of Property Owner(s): 11 12 E . W L -c` v -L S� . <br />Contractor(s)Name: AvNie 30tiscit, <br />Contract Company Name: SelliSo" Cot.OVIAr_h-Oti <br />Contractor Address: (00ci <7_ Cct vvt nil . 'n v-?. <br />City: s6l. ti' ko,�j i4O (a 4 Phone: C314- 2q 1 1 13rh <br />Current Use of Building: 'S 1k a I e - T=a V-61 1 <br />I — <br />1(SingleFandy-Mi ti -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: _ U,_ vk e _ <br />(Wood Frame - Brick - Shme - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind ❑ Landscape ❑ New replacement (not in-kind) []Demolition <br />(more Nmv one bo.r mmj be lurked) <br />r <br />0 <br />U <br />Description of Proposed Work: TO K vv VL -C L4t51-t'r- SCit-CPin - d m./ �2t 1 �l tn7rn In 3 <br />u);b-, oe o c�tAskyuch�-�n..ke A- <br />r)✓1�!/1na.Q alA< (�.; 2— a..� pOLGn �ii�c-. 11.t<',iWt'- i"Fynw WZ.lk an.� <br />rJ K-kfrJ <br />Owner/Contractor: Fax: — e-mail MQiV%Si&vg. SbGGhlaS(•Ne,�" <br />(OTZ office mill comsyond ;oith only one designee) <br />and/or <br />nI� — APPLICATION REQUIRE)WENTS ARE LISTED ON REVERSE SIDE — <br />7 CeYS c Set tdlt-:-Z f 670.0 dtrL f <br />