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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 4b601 <br />Phone: 574-735-9798 - Fax 574-235-M • Email: SBSjCHPC®co.st josephin us <br />Website: http://wwws§osephcountyindianacom/s chp/index html <br />OFFICE USE ONLY >»»y> DO NOT NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 4 Xan t a00 7 Application Number --1-0-0-7 - D �?O4; <br />Past Reviews: El YES (tate of Lot Review) <br />Staff Approval authorized by: <br />Historic Commission Review Date: / 7. Z jaZ,- 4" -2Ov 7 <br />Local Landmark (Xocal Historic District (Name) <br />[j National Landmark E] National Register District (Name) <br />AM <br />Title: <br />Certificate of Appropriateness: <br />F] Denied E3Tabled ❑ Sent To Committee F1 Approved and Issued <br />Rag <br />Address of Property for proposed work: / 7/5 r, W,4YAtF- 5-r. <br />t Street Number and Street Name <br />Name of Property Owner(s): (Please Print) j#.Vnf L.. 1.-16 A 15RAb K <br />Address of Property Owner(s): / ?/'S ?5-- L�.(r 9:7- <br />Contractor(s) Name: 45 --RAA-6 AM hvc- -- FAMP-1 ae- e,49i: <br />Contract Company Name: 6 6- A•IZ 6 4o)q e 1-1c <br />ContractorA•ddress: /02$01 4 • - <br />city -t- %k',� �te� EYZ , f . Phone: <br />Current Use of Building: rArw.- j <br />(Single Family - Multi -Family - Commercial - Government - Industrial - Vacant - etc.) <br />Type of Building Construction: 1,1000D CR, -A, -Q5 <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: [l In-kind [] Landscape N New n Replacement (not in-kind) n Demolition <br />(n orethan one box maybe checked) <br />t <br />Description of Proposed Work: D b I A U / 3- (v a .K l Gy J ��'l� t �•.! <br />&AIX, <br />rr,4cW &x <br />Owner/Contractor. Fax: e21cf- 7- D 8 7( t e— <br />mail-(M office u!4l1 ntd with only one designee) --- F3 14&Ni C,.. i g C .< Df -4 <br />and/orj/ <br />1 <br />— APPUC4 TON REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />