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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 josephin.us <br />Website http://www.sgosephoountyindiana.com/s chp/index.htinl <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONRINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received aQ D 9 - aa. II Application Number a O a 9 - 10c'11// <br />Past Reviews: ❑ VES (Date of W t Reuiely) <br />Staff Approval authorized by: <br />a • <br />Title: <br />Historic Commission Review Date: , <br />Local Landmark T<oea1 Historic District (Name) <br />❑ National Landmark ❑ National Register District (Name) <br />Certificate of Appropriateness: <br />❑ Denied E] Tabled E] Sent To Committee F] Approved and Issued <br />DATE <br />Address of Property for proposed work: 612/614 Carroll Street <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) Creat Take Property, Tnr- ( Coda T? -f— ema=---Q-rder) <br />Address of Property Owner(s): Great Lake Prop Prtsr, Tnr _ <br />Contractor(s) Name: _TBD <br />Contract Company Name: TBD <br />Contractor Address: TDA <br />City: _ Phone: <br />Current Use of Building: Garaee <br />(Single Family—Multi-Family— Commercial — Government — Industrial — Vacant — etc.) <br />Type of Building Construction: nPmnl i ti on <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: ❑ In-kind [] Landscape ❑ New ❑ Replacement (not in-kind) Demolition <br />(more than one box may be checked) <br />Description of Proposed Work: Code Enforrement nPmnl i t; nn n garages, nr Pred, 'en <br />RPhr„ary ?A_ gnn4 <br />Owner/Contractor. Fax: e-mail <br />(This office well correspond with only one designee) <br />and/or <br />— APPLICATION REQ UIREMENTS ARE LISTED ON REVERSE SIDE — <br />