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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 46WI <br />Mailing Address: County City Building, South Bend, Indiana 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email: historic@nuchiana.org <br />Website: http://communitymichiana.org/historic/ <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX >>>>>> OFFICE USE ONLY <br />Date Received 41'1,9 - 2-" G Application Number 9 4� 4 - !o lftlov <br />Past Reviews: D YES (Date of Last Review) <br />Staff Approval authorized by: <br />NO <br />Title: <br />Historic Commission Review Date: <br />[-] Local Landmark ( Local Historic District (Name) <br />[^] National Landmark M National Register District (Name) ' <br />Certificate of Appropriateness: <br />M Denied Fj Tabled M Sent To Committee M Approved and Issued <br />DATE <br />Address of Property for proposed work: 06 1 s't"� s �(✓� <br />jjStreet Number and Street Name <br />Name of Property Owner(s): (Pleassre��Print) ST = Vefti MAX S a N <br />Address of Property Owner(s):/O <br />Contractor(s) Name: _57e ✓ep Sc4 c Gee rya/ /' , <br />Contract Company Name: fQ t •t�+a,,X .J 9�t 6/e,' X 4✓j1e� �+r ✓ 1t ZO 04t d/' <br />Contractor Address:/ 8 S I 1j.c-re f -f' !(Gr s o A S __ su, e, Fl`Tm 0.94/_ DRi 16 S6 <br />City: F lq'en o fly Phone: <br />i <br />Current Use of Building- e I •y <br />V (Single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: L11990401 rl'a*I-C <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: [-1 In-kind [] Landscape F� New F� Replacement (not in-kind) E] Demolition <br />(more than one box may be clucked) j ( ( (� /j <br />Description of Proposed Work: h'� K eTa t0. /w� ts+ 1-00 1.3 / -At C. r�. � Z_ttivct..l.r� <br />b,ec,r—ea r,e Ver-PCa( rr+t 6n f�w�r oT t.r Ir►oc.sC%1 & , <br />Owner/Contractor: Fax: e-mail �- le �Q .�J�%•(>,Z.ZIv <br />(Thu office will correspond with only one designee) <br />and/or <br />— APPLICATION REQUIREMENT'S ARE LISTED ON REVERSE SIDE — <br />