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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 josephinus <br />Website: http://www.sqosephcountyindiana.com/ochp/index.htnl <br />OFFICE USE ONLY>>>>>> DO NOT COAVLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received Application Number= `_ 1 Z 01 a <br />Past Reviews: F� YES (Date of Last Seoiew) ❑ 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 />DATE <br />Address of Property for proposed work: 508 U rYiSey . • <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) Near Nori•t,weS} Nei k6orl7Dcd.=ne. <br />Address of Property Owner(s): 1004 Phy-4-n IP_ Avenue- <br />Contractor(s) Name: TD Be De}errninPll <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Phone: <br />Current Use of Building: Mul-H- Pami ly IZCStdeniial <br />(Single Family - Multi -Family- Commercial - Government - Industrial -Vacant -etc.) <br />Type of Building Construction: WOO&Pr4vne <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: Rin -kind 0 Landscape E] New [ Replacement (rot in-kind) E] Demolition <br />(more than one box mini be checked) <br />Description of Proposed Work: _P1eaSe See Su( �lernev}al lA}}Pr oG (v }en;. <br />Owner/Contractor: Fax: X544%232 -II I e-mail nnneitrnefvr t?keonlime.cow, <br />(77ds office will correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />