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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®cost-joseph.in.us <br />Website: http://wwwsqosephcounqindiana.com/sjchp/index.htn-d <br />OFFICE USE ONLY»»» DO NOT COMPLETE ANYENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received Application Number -2 o o s - I0a-8 <br />Past Reviews: YES (Date of last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark Local Historic District (Name) L,1ST WAjuF_ S_re;fFj5- <br />L National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied ❑ Tabled ❑ Sent To Committee [—]Approved and Issued <br />E <br />J DATE <br />G <br />Address of Property for proposed work: 13 3 3 . IJ <br />Stree NumbEr and Street Namj� <br />Name of Property Owner(s): (Please Print) ( Lj .) " - 1 MIA <br />Address of Property Owner(s): Z33 3 <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: S)/ -Y, 14 <br />(Single FInily- Multi -Family - Cum miall- Government - Industrial - Vacant - etc.) <br />Type of Building Construction: i'p d G✓ <br />(Wool Frame - Brick - Store - Steel - Concrete - Other) <br />Proposed Work: [:]In-kind ❑Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(marc titan one box utay becheckat) <br />1 <br />Description of Proposed Work: /X_1 4j d,lY c_( Lc (C2 - <br />C �f P i�_ (l/�Pi� •a ��P�� r` G L <br />q tr 1)t,,�e <br />Owner/Contractor: Fax: e-mail <br />(Thu office will correspond with only one designee) --- <br />and/or <br />— APPLICATION REQUIREhIENTS ARE LISTED ON REVERSE SIDE — <br />