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Application <br />- FOR - <br />Certi fYCate of Appropriateness <br />Historic Preservation Commission of South Bend & SL 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: SWCHPCekostyosephinus <br />Website: http://wwwsgOsePhcOun4 indiana.com/*hp/index.hhW <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANY ENTRIES CONRIINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received ///0'j/"0 S- Application Number o c3 S - )/0Y &, <br />Past Reviews: ❑ YES (Dateafwtit viero) 9 N <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />❑ Local Landmark Local Historic District (Name) - (,kAPi 1.) P)+" <br />❑ National Landmark National Register District (Name) C441111N FY4tV- <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: @ 4 C) i� K1 K2 1! a V E <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) 5611 N 111 b lV W V/ A t4 TT' 4 1 a S <br />Address of Property Owner(s): R 413 W K W U C <br />Contractor(s) Name: r F rr ll1 F,VO R�G� <br />Contract Company Name: \ F.K2-C CC _1� k b S O 6114- 1-- S f <br />Contractor Address: 2 0 21 A- k <br />City:�oUTH CiENh Phone: 774 2_94-,24c?1 <br />Current Use of Buildinp• S f til G -L t; F 1a tn, t LY <br />(Single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: W (' cn _Il F Y-1 %A Inn F <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind ❑ Landscape ❑ New zReplacement (not in-kind) ❑ Demolition <br />(nrore flan one box nay be checkal) <br />Description of Proposed Work: <br />C�o-I3.9LA y0�C c�.�o 1 M c��. c_ L\ <br />.- <br />Owner/C-antracter. Fax: e-mail <br />(Thu office will correspond with only one designee) <br />_ <br />—and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />