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r <br />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: 574 235-9795 • RLx: 574 -?1.5-97/S • Fanrul: SBSJC HPC( tko.st josephimtLs <br />�ltetnite: http://�vti�►.stjosel�hraiultyuuli�uui.crnn/sichl+/uuiex.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTAINED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received �Application Number ���� - 041-P <br />Past Reviews: Ei MS (Date of Zast Rev&w)% ! it NO <br />Staff Approval authorized by: <br />Title: <br />Historic Commission Review Date: C <br />Local Landmark [T Local Historic District (Name) G • W.ArA' <br />National Landmark [:] National Register District VVatne) <br />Certificate of Appropriateness: <br />Denied E] Tabled E] Sent To Committee ❑ Approved and Issued <br />DATE <br />Address of Property for proposed work: 0 P SI 1v <br />Sheet Number and Street Name <br />Name of Property Owner(s): (Please Print) f �r� Q r1�0 - Q V ( / e I T. 1(}' i f to <br />Address of Property Owner(s): I a U ( W o;, �Q 51 !J <br />Contractor(s) Name: Poi ti CV- P 411 o r\ <br />Contract Company Name: A 6W J1^ i o n s (0 0 l o n <br />Contractor Address: 155-110 (.fir e, Pd <br />City: 0 5 (PA � a _r r `9 6661 Phone: ei7 H 6-7 `- 9300 <br />Current Use of Building: 5 t neq (' `CM,14 <br />(Single Family —Multi -Family —Commercial —Government —Industrial — Vacant —etc.) <br />Type of Building Construction: <br />(Wood Frame - Brick - Stone - Steel - Concrete - Other) <br />Proposed Work: E] In-kind [-] Landscape Ej New ®Replacement (not in-kind) n Demolition <br />(mm than one box may be checked) <br />Description of Proposed Work: 'e�tor Q f fC C" �0� r� {JI y (/�/�I0(eMl7111 0'( <br />41de Pe\k(j 4oer rxnri c��drlt�r� v� S��P�� �,,,� 5tiltlM Ivor" <br />1V 4(deI-nvd3af Lyer%P rinffL4 door" Ale tq(j/1- Sr'Rref) <br />f;eft rrs. or iorS of feck'd r <br />Owner/Contractor: Fax: e-mail (k)00 ro OL <br />(This o ce will corresixmd with only one desigmee) J <br />�"f� and/or <br />— APPUCA77ONREQUIREMENTS ARE -LISTED ON REVERSE SIDE — - <br />