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4 <br />Application <br />- FOR - <br />Certificate icate o f 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: SWCHPMcost joseph.in.us <br />Website: http://www.sqosepha)un4indian&com/s chp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CON711INED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received G A4sieo2 DD 7 Application Number a O O 7- 4811 8 <br />Past Reviews: ❑ YES (Date of last Review) ❑ NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: C2 0 0 7 <br />❑ Local Landmark ❑ Local Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied ❑ Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: 50-8 - 5-C9 <br />16 IIII.IFq <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) -- 'fP `f' }I j ��=lC� IKLC -, <br />Address of Property Owner(s): �• 1�C�X c j"t't-I•l�t (1�1 �{�O(!� <br />Contractor(s)Name: _�T 1 ,p�v-- M� <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Phone: <br />Current Use of Building. C' <br />(Single Family — Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction:- Nn'I FEP*_-{E <br />(Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />Proposed Work: WIn-kind ❑ Landscape ❑ New ❑ Replacement (not in-kind) ❑ Demolition <br />(more than one box may be chccW) <br />Description of Proposed Work: l ►1,(t�, A1.1�J <br />"IT44 -_4Ar cM-1 CiatAt a rr- 4=iROz cr i71 vjPT 4► \ In ID -I <br />:ftjrj 71Fq_TLr'%P c'T�tcat <br />Owner/Contractor: Fax a�— i 1 .41 e-mail I.11.11�1D1e1� � [' e�V tt �F ,Cfsi•� <br />(This o/fi x will corn7ond with only one designee) <br />. �-':•' r,NMpn Tom. I «LII!er► •IIII•Iiioiii III !C <br />— APPLICATION REQIIIRFMENTS ARE LISTED ON REVERSE SIDE — <br />