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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 • Email: SBSjCHPC@co.st-josephdn.us <br />Website: http://www.stjosephcountyindiana.com/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received /8 OC -7 200'% Application Number g'o 09 - <br />Past Reviews: El YES (Date of Last Review) ERNO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: 16 / o v 200,9 <br />R Local Landmark IRtoeal Historic District (Name) 'e5-10,9AmE <br />❑ National Landmark F� National Register District (Name) <br />Certificate of Appropriateness: <br />Denied E] Tabled ❑ Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Propert for proposed work: 11c* le WA <br />y `%Street Number and S eet Naml <br />Name of Property Owner(s): (Please Print) QVipd <br />Address of Property Owner(s): <br />Contractor(s) Name: UA y AP_ RA,1 ik o eA ' " <br />Contract Company Name: ' J 10 <br />Contractor Adyj�1ress. / a //r <br />City: f /�S Ii'GJA1.11A oU/1� �5I` T Phone: , <br />Current Use of Building: <br />lSingte Family — Multi -Family Commercial — Goz err rneht — Industrial — Vacant — etc.) <br />Type of Building Construction: <br />Proposed Work: � In-kind <br />(more than one box may be checked)/'� <br />(Wood Frame — Brick — Stone — Steel — Concrete - Other) <br />❑ Landscape Fj New Replacement (not in-kind) E] Demolition <br />Owner/Contractor: Fax: <br />(This office will correspond with only one designee) <br />67 1213 RD <br />LE'3 09 <br />and/or <br />e-mail 2 n_ (Z� -Ad 1(m <br />— APPLICATION REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />