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Application <br />- FOR - <br />Cervi f irate of Appropfiateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Idayetie Blvd., South Bend, Indiana 46601 <br />Mailing Address: County -City Building, South Bend, Indiana 4660i <br />Phone: 574-235-9 98 - Fair 574-235 9578 - Email: SBSJCHPC@w st+oseph.in.us <br />Website: http://www.sgosephcountyindbmcom/*hp/indo hhnl <br />OFFICE USE ONLY »>»> DO NOT COMPLETE ANY ENTRIES CONAINED IN THIS BOX' »r>r> OFFICE USE ONLY <br />Date Received a'Q 7911V a047 Application Number!9 Cr G Z - 062-9- <br />Past Reviews: [1 YES (aoteo/ca t F *w) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />Local Landmark <br />E] National Landmark <br />Certificate of Appropriateness: <br />[Local Historic District Waste) <br />❑ National Register District (Name) <br />■ • <br />Title: <br />F] Denied F] Tabled ❑ Sent 7b Committee E] Approved and Issued <br />Address of Property for proposed work: 5107 t 4- S/ <br />Shat Numberand Stmt Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): <br />Contractor(s) Name: — r <br />Contract Company Name: <br />Contractor Address: <br />DATE <br />. ; cfq• 0 5-Ij <br />City: � Phone: 2,?7—/ <br />'� <br />1 001, dell.,it o -fit IZ <br />Current Use of Building: <br />(Singe Family — Multi Family _mw — Gaoernrnent — rndurtrial — Vaaant —etc.) <br />Type of Building Construction; 10DA-P <br />(Wood Frame — Hrkk - Stone — Steel — Concrete — Other) <br />Proposed Work- ❑ In-kind Landscape New (,X Replacement (not in-kind) [] Demolition <br />(marc than one box may be eherW) <br />Desffiptlon of Proposed Work:�I&T, <br />`�- v'611,✓ ? o. <br />�• � 9 r� 1 ;�� I�w.�,�.� ��� axe <br />Owner/Contractor. Fax e-mail rJ <br />(9hia ojlice wi only } /" S <br />g and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />