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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: 57¢235-9578 • Email: SBSJCHPCQco st josephinus <br />- Website: http://www.stjosephcountyindiana.com/sjchp/index.html <br />OFFICE USE ONLY »»» DO NOT COMPLETE ANY ENTRIES CONTUNED IN THIS BOX »»» OFFICE USE ONLY <br />Date Received Po i� % Application Number a 9 - %OG G <br />Past Reviews: YES (Dateoftast Review) NO <br />Staff Approval authorized by: Title: <br />Historic Commission Review Date: c20„ <br />Local Landmark [r] rocal Historic District (Name) Ir. A&44� <br />National Landmark National Register District (Name) <br />Certificate of Appropriateness: <br />Denied Tabled E] Sent To Committee Approved and Issued <br />DATE <br />Address of Property for proposed work: V104 kk) 4YQe, -S+-, <br />Street Number and Street Name <br />Name of Property Owner(s): (Please Print) <br />Address of Property Owner(s): AAM 1E_ <br />Contractor(s) Name: gos jer SIG�(.r1� `( <br />1I (f rt <br />Contract Company Name: <br />Contractor Address: I KOLL 11s <br />City: .7-A% _ 4&5jo Phone: tint}'.. 6;)74_S,5g9 <br />Current Use of Building: L lilvia ( r <br />(Single Family — Multhamily —Commercial —Government —Industrial — Vacant — etc:) <br />Type of Building Construction: U)oFA&ML- 95.3 ; ilt, <br />1 (Wood Frame — Brick — Stone — Steel — Concrete — Other) <br />�l1�NflO� tC�Winl�ou"1 <br />Proposed Work: ® In-kind n Landscape New X Rept cement (not in kind Demoliti� <br />(more than one box may be checked) /11 p 5,4mE <br />Description of Proposed Work: 15 to 4/1M id, n t'�6Vj DoQzs✓l�:' (,(%�/ji�m(t�iX %SQiQF/IZU11�� <br />i�G-t <br />Q�ft Iry Nor�n.m Lc Ccs. Cl nil l.t�i.t n�c �?Z �c�t� �' <br />&&nPontra27to_r) <br />�sYl N <br />OwnerFax: -J`f e-mail <br />(This office will cormand with only one designee) home -own, <br />, <br />x9 71�/QPato►� and/or l�.�l , i'/ _f ! ome-oW Yn <br />— 75 - <br />"PLICA -HON REQUIREMENTS ARE LISTED ON REVERSE SIDE — <br />