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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 46601 <br />Phone: 574-235-9798 • Fax: 574-235-9578 • Email: SBSJCHPC@co.st josephinus <br />Website: http://www.sgosephcountyindiana.com/s dip/index.htinl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX >>>>>> OFFICE USE ONLY <br />Date Received % Application Number a C 6-.,? <br />Past Reviews: [Z/YES (Date of Last Review) 13-1'3 - 20 C 7 <br />NO <br />Staff Approval authorized by: <br />Historic Commission Review Date: 2.1 U ;L00 8 <br />Local Landmark L,�'l:ocal Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Title: <br />Certificate of Appropriateness: <br />Denied ❑ Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />Street N4)b r and Street Name <br />Name of Property Owner(s): (Please Print) ,M ` `'�r'�- ` ''� <br />Address of Property Owner(s): Z� 3 4 ' `l``"�� �- t) 317 q �6 77 <br />Contractor(s) Name: t3 w `^ t:. �- <br />Contract Company Name: <br />Contractor Address: <br />City: ,Phone: <br />Current Use of Building: �` �"" ) <br />(Single Family — Muh mily — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: UJ O'A P`r e.. e-, <br />(Wood Frame — Brick — State — Steel — Concrete — Other) <br />Proposed Work: ❑ In-kind n Landscape ® New ❑ Replacement (not in-kind) [:] Demolition <br />(more than one box may be checkaf) <br />Description of Proposed Work: 'T-1 �`S t -C. �� C' �'1J <br />Ut f ✓1 C �� ii C+N <br />Owner/Contractor: Fax: e-mail <br />(Thu of jceI car with}�dy ne ccignee) <br />�J and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />