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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: 574235-9578 • Email: SBSJCHPC@w st joseph.inus <br />Website: http://www stjosephcountyindiana.com/sjchp/index.html <br />OFFICE USE ONLY»»»'DO NOT COMPLETE ANY ENTRIES CONIA NED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 90r-Za" o200 ? Application Number <br />Past Reviews: ❑ YES (Date of last Review) [] NO <br />Staff Approval authorized by:. Title: <br />Historic Commission Review Date: old <br />[� Local Landmark Local Historic District (Name) <br />E] National Landmark ® National Register District (Name) <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 Number and Street Name ,.�/ <br />Name of Property Owner (s): (Pimse print) �+ T-6 f a. <br />lt ! —,0 � L . /�'�/� ��'RU <br />Address of Property Owner(s): _ - f l �--� ciL`- �Q.- 7L -2A /lam <br />Contractor(s) Name:�1� <br />Contract Company Name: _ . .... _ . <br />Contractor Address: <br />City: Phone: <br />Current Use of Buildings <br />0—ingleamil–Multi-Family – Commercial–Government – Industrial – Vacant – etc.) <br />Type of Building Construction: <br />I ' VWd Frame – 8 'dc –Stone – Steel – Concrete – Other) <br />Proposed Work: ❑ In-kind [] Landscape New ❑ Replacement (not in -land) Demolition <br />(more than one boat my be duxlced) <br />Description of Proposed Work:�- <br />Owner/Contractor. Fax. <br />(I office u"reapmui / onlny one_de <br />l n /_ _c <br />- APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />