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J <br />• Application <br />- FOR - <br />Cernficate of Appropriateness <br />Historic Preservation Commission of South Bend & St Joseph County <br />125 S. Lafayette Blvd., South Bend, Indiana 466()1 <br />Mailing Address: County -City Building; South Bend, Indiana 46601 <br />Phone: 574-235-9798 - Fax: 574-235-9578 - Email: SBSjCHPC@lco.st joseph.in.us <br />Website: htip://www.sgosephcoui4indiana.com/sjchp/index.hbnl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES• CONDtINED •IN THIS BOX »»» OFFICE USE ONLY <br />Date Received 407l y Application Number A 4D _ D 70 3 <br />Past Reviews:. ❑ YES (Date of last Review) <br />Staff Approval authorized by: <br />■ M <br />Title: <br />Historic Commission Review Date: / �Q <br />Local Landmark Local Historic District (Name) <br />E] National Landmark National Register District (Name) <br />Certificate of Appropriateness: . <br />E] Denied R Tabled E] Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: GO 5 R e,!,c S'i r e r 4 - <br />Street Number and Street Name <br />Name of Property Owner(s): (Please print) -I c%"% <br />Address of Property Owner(s): _•_13 4 A F•Q.r es+ * AMC- <br />Contractor(s) <br />vC- <br />Contractors) Name: e GU1 en e r1 'B a 11 ► rw i <br />Contract Company Name: '�3 e ll i r, , LanA s C.4P e✓ n et 'Dc -S tQ n <br />J <br />Contractor Address: St/ ei L^ c o 1 n W 0'3+ - <br />City: M I. S k O w a k cL 1t -j Phone: 2.52, CIS 19-2— <br />Current <br />9ZCurrent Use of Building: S I n g t e- •'o n,� j d <br />(Single Family — Multi-Famiry — Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: -F eAn e e <br />(Wood Frame— Brick— Stone — Steel — Concrete— Other) <br />Proposed Work: In-kind 0 Landscape New. ❑ Replacement (,rot in-kind) Demolition <br />(more than one box may be chwM) <br />Description of Proposed Work: e b n; ^ " u r 'r r- ^ n < < &no " eN d <br />to s C. n 1 o k -irr o c r. a 11 . <br />Owner/Contractor: Fax: <br />(This office wAl co r d with only one designee) <br />— APPLICATION REQIHREMENTS ARE LISTED ON REVERSE SIDE — <br />e-mail J 0 v w hs Q t U 3 b, e A H <br />3 S Ind or <br />