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-0 - C4 4o -t <br />Application <br />- FOR - <br />Certificate of Appropriateness <br />Historic Preservation Commission of South Bend & St. Joseph County <br />125 S. Wayette 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:- SBSJC 1PC@co.st joseph.inus <br />Website: http://www.sgosephcountyindiana.com/s chp/index.html <br />OFFICE USE ONLY »»n» DO NOT COMPLETE ANY ENTRIES COMAINENO <br />HIS BOX >"" OFFICE USE ONLY <br />Date Received OD. 2A. 20 Application Number Q (- O <br />Past Reviews: 0 YES (Date of fast m iew) [:] NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: <br />12/Local Landmark R Local Historic District (Name) <br />National Landmark E] National Register District (Name) <br />Certificate of Appropriateness: <br />Ej Denied [] Tabled F� Sent To Committee [] Approved and Issued <br />DATE <br />Address of Property for proposed work: 10 V 1 t <br />P P P <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Ow rrY(�,$)). CAMO ,e � C Vv <br />Contractor(s) Name: U/ V V t�r& Vb w <br />Contract Company Name: ( <br />Contractor Address: <br />City: <br />Current Use of Building: <br />le Fart ily — Multi -family — Cc <br />Type of Building Construction: ucc 1 0 DIVU <br />(Wood Frame — <br />Proposed Work: [2/ln-kind [E/Landscape ❑ New4 <br />(more than one lax may be checked) � t <br />Dc cription o P o ed or +1p1' <br />qf�" i -Tv (n Tky, AAj w4of <br />Owner/Contra r: x. e-mail <br />( is c wdI n r wi r ly on cignce) <br />and/or <br />Phone: <br />`—^Gov^en�n 6dustrial — v nt — etc.)Uft tco N <br />a re — Steep Concrete — O) CQa[�i <br />- 1 <br />~placement (not in-kind) ❑ Demolition <br />1 <br />— APPLICATION.REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />