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Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & SL Joseph County <br />12R kfayette Blvd., South Bend, Indiana 951 <br />Mailing Address Counly-ity Building, South Bend, Indiana 951 <br />Phone -3-2) • Fax: 9-29 • EmaiL• histonceichiana.org <br />Website: http://commurli"chiana.org/Nstotic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMP! FT -F ANY E7VIRrcc Cnw BOX »»» OFFICE USE ONLY . <br />Date Received 7 At',0 Ee 4,05 Application Number 4 O OS - /DO 7 <br />Past Reviews: E] YES (tate of Last Renins)_ f -I NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: OOS <br />F] Local Landmark [✓]Local Historic District (Name) <br />❑ National Landmark [National Register District (Name) C!/gpn✓ <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee 0 Approved and Issued <br />DATE <br />Address of Property for proposed work: 3 O 8 LP M a N Tf, rt F r <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) _ S l4 EI2 YL_ + JON O ( I -t 19N OE�2J\f o 0 <br />Address of Property Owner(s): (,20 B Ll M <br />Contractor(s) Name: <br />Contract Company Name: S C k L E LL _FE&) CC <br />Contractor Address: 2Z3--1 A -Dew I S i?_b <br />City: SGA�_TA+ (?C"cJ - Phone: 2- 7 2 9 2-OCD <br />Current Use of Building: <br />(Single Family Multi -Family- Commercial - Government-Industrial <br />-Vorant <br />- dc.) <br />Type of Building Construction: <br />(Wood Frame Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: E] In-kind Landscape E] New E] Replacement (not in-kind) Ej Demolition <br />(more than one box may be checked) WOOD <br />Description of Proposed Work: N e - W <br />W OOD Fe r ja I- FT d N Q( <br />CVF09e P_TY LItj t_ IF i Se COQ_Je2 (e6av ) -om - BoapD ) <br />DA) T) +FTTRLI- 00 Sllle OF j+0U.SC TV rklS>-ING (--edJC� —r4(5 ST It C tz)Oui ] (3t "�/ tl l F��e2 �" (SC—G O966"U12E) <br />Owner/Contractor. Fax: e-mail Shery (Vernon @(a -o ecrn <br />(This office volt correspond unfh only one designee) <br />i and/or <br />Signature of Owner- V11 LIQ STg ature of Contractor <br />— APPLICATTON REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />