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V <br />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: SBSJCHPC0aco.st joseph.in.us <br />Website: http://www.st osephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY <br />,»/»» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received �7 L 02008 Application Number o� 00� _ O.Z Al <br />Past Reviews: YYES (Dale of Last RMety) <br />Staff Approval authorized by: <br />Historic Commission Review Date: <br />Wy 4� .200' F] NO <br />Title: <br />[ v Local Landmark [ <0cal Historic District (Name) <br />F1 National Landmark [ej<ational Register District (Name) <br />Certificate of Appropriateness: <br />R Denied Q Tabled E] Sent To Committee R Approved and Issued <br />DATE <br />Address of Property for proposed work: '7710 retyk Ayo- <br />Street�Nlumbeer/and Sty -eel Name <br />� <br />Name of Property Owner(s): (Please Print) 1.7 e7 C� � � s °te0 to <br />Address of Property Owner(s): <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: <br />Current Use of Building: <br />Type of Building Construction: <br />710 Potik Ave . <br />J&C,�, ' frlk G(AVCH e <br />Rowe S'rr Ice_ <br />G7E6 21 Mu 6ovr ktc acA <br />00WCAgt AC w M1 Phone: 574 220 47S <br />& vvR l am.,6,wly . <br />(Single Family/^ -1 Multi -Family — Commercial — Government — Industrial — Vacant — etc.) <br />rvood &WP <br />(Wood Frame — Brick — Stone. — Steel — Concrete — Other) <br />Proposed Work: n In-kind FjLandscape n New [Replacement (not in-kind) F]Demolition <br />(more than one twx may to checked) /n1 // fl, -\C.5,,/ / <br />Description of Proposed Work: -AKrI k%odo( -04fl,-\C.5vl(44b(e-A�'j 1 �(ii llo\ <br />S�Fd � o�C S�l,�s ii-. s�e h(acsL <br />Owner/Contractor: Fax: T4 63( s2ss- e-mail �Q Acte,r1E, #4A <br />(This office Wnll un•re-SpOnd With onht one designee) <br />and/or - <br />- APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />