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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 • Eniail:SBSJCHPC@,co.st-joseph.in.us <br />Website: http://-v�qvw.sqosephcountyindiina.com/s clip /index.htnil <br />OFFICE USE ONLY » »» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX » »» OFFICE USE ONLY <br />Date Received •e14AA__ °Z� / Application Number � - 0 10 6 A <br />Past Reviews: F YES (Date of Lost Review) NO <br />Staff' Approval authorized by: Title: <br />Historic Commission Review Date: 0f a 2VO 9 <br />Fj Local Landmark EKocal Historic District (Nance) ��+wrc TcL2r <br />R National Landmark Ej2lKational Register District (Name) <br />Certificate of Appropriateness: <br />E] Denied F� Tabled R Sent To Committee . Approved and Issued <br />DATE <br />, C <br />Address of Property for proposed work: V 1 �VyS <br />/ 1V y.- <br />Street Number and Street Name <br />r 5 tit <br />ew, 6 <br />f� nun <br />I <br />City: r, Va r mi , TI`( (16x_'(7 Phone: <br />-- <br />Current Use of Building- �tW r <br />OAP �t- aw);lta <br />(Single Family - Multi - Family - Commercial - Government - Industrial - Vacant - etc.) <br />Name of Property Owner(s): (Please Print) _ P 0 v_e 11 rl1 <br />Address of Property Owner(s): $M9 fowyk lA2 _ <br />Contractors) Name: — M 6"S AAdVk� <br />Contract Company Name: { - f Lti1 &d vi'.0 C'n <br />Contractor Address: `p© R (A< <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: E] In -kind F� Landscape [� New Replacement (riot in -kind) F] Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: !'�Lti lC� C'^�i'i Ct 'QY �1��►� G�2(� -/ 2t�3 c� �Cc ei' - 9tiy - u r(&ii N1 A <br />r � <br />te-v A A d r 0 + O'AC W d Lk C i'►5 W - 01 0 J 6C t h:At a <br />�( `tilrlt t/hG��"Z� th -�i -al n GP t p�rr�t �.i�c?_d to 05. <br />NtAld t .+i Ik lv'� � d1 s 4.jLA � MAU k & V 6t t �rn7� <br />- jk �11 - o d � �ac� �c(�etr <br />ner /Contractor: Fax: a- mail t/� P.0 -� J�C�t fi✓h <br />(This office will correspond with only one designee) <br />Type of Building Construction: I Alb t d �YI - tvh-e. <br />and /or - <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />