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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: historic@michiana.org <br />Website: http://communitymichiana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received o?Od % Application Numbereg la4 % - <br />v <br />Past Reviews: [:] YES (Date of Last Review) NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: Ali 6� ;'da % <br />Local Landmark [B<ocal Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied E] Tabled F_� Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: ✓/� UJAYt i- s j <br />Street Nurf6er and Street Name <br />Name of Property Owner(s): (Please Print) Sp (' t"-1/ -60 ST I I -11 <br />Address of Property Owner(s): 15/2- E WAYNE . S. 73 . J- A� y hIC <br />Contractor(s) Name: 1J 111 11Tr LN PE"i T�i4A/ 1 <br />Contract Company Name: ' <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: SIA1641,6_ FrtM 1 Ly <br />(Single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: In-kind (2 Landscape F)<l New E] Replacement (not in-kind) [:] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: WCC) lam.-rt/CF7 F_ E 1JL D� OP:�1.Q 0,P <br />Owner/Contractor: Fax: e-mail sAt! L4`T/C14� SSE C��3AL ,'� <br />(This o1ce will conmspond with o# one designee) 1 <br />and/or <br />Signature of Owner - Signature of Contractor - <br />- APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />