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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 -235 -9578 • Email: SBSJCHFC ©cost joseph.in.us <br />Website: http:/ /Www.sgosephcountyindiana.com /s chp /utdex.html <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />k Ap Number .lea z - d 7L 9 <br />/ G <br />Date Received ° PP Ir <br />[] NO <br />Past Reviews: D YES (Date of Lot Review) <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: u a� '� f <br />Local Landmark ® Local Historic District (Name) <br />D National Landmark f_� National Register District (Name) <br />Certificate of Appropriateness: <br />Denied [] Tabled � Sent To Committee [] Approved and Issued DATE <br />Address of Property for proposed work: r a?? C' t�A �C- •- 1. /-364174 <br />Street Number and Street Name. <br />Name of Property Owner(s) (Please Print) <br />Address of Property Owner(s): v <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: / Phone: <br />Current Use of Building: Sin IL (` <br />ingle Family — Multi-Fa — Cotmnercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />(Wood Frame — Brick —Stone —Steel — Concrete — Other) <br />Proposed Work: E] In-kind Landscape E] New ❑ Replacement (not in kind) E] Demolition ; <br />(mare than one box may be checked) <br />Description of Proposed Work: ��� - - ---rr- Zrr <br />ZALPS <br />See L/( o�1�t2f3u5/#1 %Au/A11 A�sv �c�n ��riT �3u5�E� <br />Owner /Contractor: Fax: e-mail / S <br />(This o ce t correspo onI one designee) <br />V �`' and /or y <br />r� <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />