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e <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 11-41A C" South Bend, Indiana 46601 <br />Phone: 574-235-9798 - Pax: 574235-9578 - Email- SBSJCHPCaOco.st joseph.inus <br />Website: http://www.sgosephcountyindiana.com/sjchp/itidexlitnil <br />OFFICE USE ONLY »»» DO NOT COMILEIE ANY ENTRIES COiV711INED IN 1TIIS BOX »»» OFFICE USE ONLY <br />Date Received 8� oZ 40�' Application Number _4_0 <br />Past Reviews: ❑ YES (Date of Inst Review) Ej NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 02! oZ00 8 <br />Local Landmark Pq Local Historic District (Name) <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />Denied ❑ Tabled n Sent To Committee n Approved and Issued <br />DATE <br />Address of Property for proposed work: <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) S R a h S o ✓1 <br />Address of Property Owner(s): -1 \A o h <br />Contractor(s) Name: <br />Contract Company Name: <br />Contractor Address: <br />City: Phone: <br />Current Use of Building: �G I�I <br />l (5ingl`M1^ i P iiiy — <br />Multi -Family — Comnfercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: `^^ 'e <br />(Wood France - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: M In-kind ❑ Landscape ANew Fj Replacement (not in-kind) n Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: e xi J S V - (L -&'e_ P <br />XV -"%_S %b w�i 4�e-A <br />Owner/Contractor: Fax: D e-mail <br />(This`of fico will correspond with only one cppiesigru <br />and/or <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />