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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: 574-235-9578 • Email: SBSJCHPC@co.st josephin.us <br />Website: http://wwwstosephcounq-indiana.com/schp/index.hbrd <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTWNED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received t'-/ 0 7 1 0ti Application Number -a O c'! . z` I A <br />Past Reviews: ❑ YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />❑ Local Landmark 0 Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />0 NO <br />Title: <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: .J508 U M-sey <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) Near Nor+(,wes+ bjQ;�Wprinorxi . Inc. <br />Address of Property Owner(s): 100-+ Porn t�e_ Avenue_ <br />Contractor(s) Name: To Be. De.+ermik rd <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Phone: <br />Current Use ofBuildina• M_u_l_+i-fnw„ity Re51d,•n}ici1 <br />(Single Family - Multi -Family -Commercial -Government-Indnstrial -Vacant -etc.) <br />Type of Building Construction* W00d4aw11a <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind E] Landscape [] New ❑ Replacement (not in-kind) [Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Please Sea SutlPmrvrFal lri+e o; tv}evtt. <br />Owner/Contractor: Fax: (54)232-1145- e-mail nnnc(tre.efor L�I<eonl ne.com <br />(Thos office unll correspond with only one aesiymee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />