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'�Nw <br />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 -235 -9578 • Email: SBSJCHPC ®co.st joseph.in'us <br />Website: http://www.sqoselihcountyindiana.com/sjchp/il <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received 14 (" ,ZOO � Application Number oZ O <br />Past Reviews: E] YES (Date of Last Review) <br />Staff Approval authorized by: <br />Historic Commission Review D <br />F] Local Landmark <br />National Landmark <br />Certificate of Appropriateness: <br />Denied [:] Tabled <br />E] NO <br />Title: <br />ate: 0f 00 7 <br />[cal Historic District (Name) <br />O ational Register District (Name) <br />[] Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />Strt umb r rtd Street Name. <br />Name of Property Owner(s) (Please Print) <br />Address of Property O ner(s): <br />Contractor(s) Name: Z rv�� <br />Contract Company Name: -� <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: <br />(Single amity — Multi- Family — Cotrtrttercial — Government — Industrial — Vacant —etc.) <br />Type of Building Construction: <br />(Wand Frame —Brick —Stone — steel — Concrete — Other) <br />Proposed Work: [] In -kind E] Landscape MNew ITReplacement (not in- kind) [] Demolition <br />(rrtore than one box may be checked) <br />Description Pr posed Work: <br />Owner /Contractor: Fax: e-mail <br />(This of�i rres nd with only one d • nee) <br />and /or y. <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />