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Application <br />- FOR - <br />Certificate icate o f 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 -235 -9578 - Email: SBSJCHPC®cost Joseph imus <br />Website: http: / /wwwsgosephcoungindiana.com /s chp /index.htnil <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONT TUNED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received 13 )!*&L AM 7 Application Numberoj - O 5e A <br />Past Reviews: [] YES (Date of Last Review) F NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />Local Landmark F� Local Historic District (Name) <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied [] Tabled [] Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: I J/ g t''' VN C' 01 `✓� `� ` G i %L <br />,,Street Number and Street Name <br />Name of Property Owner(s) (Please Print) <br />Address of Property Owner(s): z ,D 9:) '� ��'�� ��F. /V <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: S : , � J ' " <br />(Single Family - Multi - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: \ <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: [] In -kind ❑ Landscape New ❑X Replacement (not in- kiwi) El Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: + J' V_\ U j: r h V',,, V_ Cl ( � <br />I , -�v. �C d'uJtM . � ��� �Gcvir -� G... J wr `-� � � �...' J � 1r. -�'��C ✓'C.�'�1' 6T <br />OwnerlContractor. Fax: e-mail <br />— OjJice will correspond with only one designee) <br />r - "~ Z 71 and /or <br />— APPLICATION REQUIREMENTS ARE LISTED ONREVERSE SIDE — <br />