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Applicafion <br />- FOR - <br />Certificate of Appropriatetiess <br />Historic Preservation Commission of South Bend & SL Joseph County <br />125 S. Lafayette Blvd, South Bend, Indiana 46601 <br />Mailin rl�c r <br />* " -fl, C_ <br />AA I �y '-r. U LM11U, In diana 4MUL <br />Phone: 57-1-235- • Fxc57 • EmaiL- his <br />Website. http://communit)rrn chiana.org/historic/ <br />A Certified Local Government <br />OFFICE USE ONLY >>>>>> DO NOT CO&[LLL7FANY E,)gRIFq CON7d1XE21N_ THIS _RQX >>>>>> OFFICE USE ONLY <br />Date Received Application Number 0 <br />Past Reviews: &rES (Date, RmLnv) y /fir 2 av 7 � -NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: AMA ,.1(O i <br />F� Local Landmark <br />latocal Historic District than,) <br />f National Landmark ❑ National Register District (,matne) <br />Certificate of Appropriateness: <br />r Denied L] Tabled M Sent To Committee M Approved and Issued <br />DATE <br />Current Use of Building- 5--1iV6-ZC '-I, <br />(Single F4rnil , q- Multi-Family - Comnie al - Goternment - Industrial- Vacant -etc.) <br />I 'r <br />Type of Building Construction: e5 <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Contractor Address: <br />Cit 117,),,5,1J11tV4k4 Phone- <br />Contractor(s) Name: CA 10/i/ tvl�vl)&Os Hoity L �,etr lidl- <br />V <br />T, A J r <br />Contract rn— /"-/] f f - I I 1,1 <br />e <br />Address of Property for proposed work: AV 4 VAle, ff J, <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): 0 q (!Z- 61.) VAI C-1 <br />Proposed Work: Lj In-kind Lj Landscape F1 New Replacement (not in-kind) E] Demolition <br />(niore Ifxn one box tim be citeckrd) <br />Description of Proposed Work: Vj / e- 4v <br />V l"Ioo�t )C <br />Owner/Contractqr� Fax: e-mail <br />(ritis qyicr will only one i ee) <br />, 6io <br />and/or <br />Signature ' of Owner Signature of Contractor <br />-- APPLICATION REQUIREVIEWSARE LISTED ON REVERSE SIDE — <br />