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11E. -1 )� iC:2j . 1U:24'ir.6? 5117 = <br />Application <br />—FOR— <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend Bc St. Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 46601 <br />Phone: 574235-9798 - Fax: 574-235-9578 • EmaiL historicOn-dchiana.org <br />Website: http://co urtitymichiana.org/historic/ - <br />A Certified Local Government <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANY EMAIE.S rr)V-AtNFf) IN THIS R= »»» OFFICE USE ONLY <br />Date Received ,..2.11 7 O�j Application NumberZ O O 4 - l2,ot9 <br />Past Reviews: ED YES (Darr of tssr Review) <br />Q NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date- O I /-Zy / OS <br />r - <br />Local Landmark Local Historic District (N.md <br />National Landmark National Register District (N.me) <br />Certificate of Appropriateness: <br />F-IDenied Q Tabled E] Sent To Committee Q Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />51ree1 Number and Sfarf Nmne n <br />✓r.J vim'! /a5i f'r <br />Name of Property Owner(s): (Please Print) 9Lrln -7_U2F1_ i - i e 2 6C <br />R �PLc._vt l/ <br />Aress of Property Owner(s): 1 Q F . a C C ST f2lr-," �/1.5 4 S <br />Contractor(s) Name: A-b +-C <br />Contract Company Name: 117. 39-4 n Ori e�; rnn ay go ' L <br />Contractor Address: 4'1::� :)A Cnun'-� " <br />City: rnrhP re tL1 fes. -7 7? 1 Phone: <br />Current Use of Building: tin r_ <br />(Single Faniil�— Mufti -Family — Comnmreia Gnvon merit—f .Su>bial—Vacard—efe.) <br />_J <br />Type of Building Construction: <br />(Ward Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind C] Landscape E] New f--] Replacement (not in-kind) 0 Demolition <br />(morn ttun one box may br checked) l f / <br />Description of Proposed Work: �-Q7 eG 1 (PN� r> . T� .-7 � c iT r -'F'[ <br />:S Ynca Y"�✓I��7C.�c- <br />h., ezi-,C <br />ti Ener/Contractor. Fax: 7 C�//to e-mail s=„Y7 4-,,f r YYIF Eq Q �. <br />a OM <br />.office will correspond with only one durg... t) <br />�r �. %/) �/ and/or <br />�Signatvre (Jtuner Signature of Contractor <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />